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Home My Public Portal About6142 IVAR AVE_Building__ F?ORKERS' COMPENSATION DECLARATION '�ib r 3 WTh.� leer i%,affirm that I have a certificate of consent'fo self O �^-insw�} or 6 certificate OO of Workers' Compensation Insurance, �.� C7111� D O�M or a certified copy thereof (Sec. 3800, Ldb. C. / �' �/ COUNTY OF LOS-ANGELES ' BUILDING AND SAFETY ti+ Policy No./ Companyo�T/��P �'{�t!^�i Certified copy is hereby furnished. FOR,APPLICANT'TO FILL IN BultDwG / �p a ❑' ADDRESS I Certified copy is filed with,the county building inspec- BUILDING. 1 �L `-� tion department. ADDRESS, �� 1 11A/Z Ave Date d ,APPlicantre'� L CITY. liti� ZIP LOCALITY f CERTIFICATE.OF EXEMPTION FROM WORKERS' ` / NO.OF BLDGS. NEAREST COMPENSATION'INSURANCE_ SIZE OF LOT NOW ON.LOT CROSS T. -• (This section need;not be'completed if the permit is for.one', ASSESSOR.,' hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL s TEL. n US ZONE: -:MAP J I certify that in the performance of the work:,for.whjch this OWNER �- � :NO.�Cl4� NO. �•: ��(� permit is issued, I shall not employ any person in any manner /, L SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS 1 U� { CONDITIONS ' ZIP• - Date Applicant ARCHITECT OR TEC.` ' O NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GRUP TYPE FIRE PROCESSED BY ENGINEER NO. . ZONE Exemption, you should.. become subject to the Workers' r, p CONST. Compensation provisions of the Labor Code; you must forth- ADDRESS with comply with such provisions or this permit shall be ` TEL, STATISTICAL CLASSIFICATION APT. CO deemed.revoked. e 7 CONTRACTOR Jd � N0. }s7 V L -LICENSED CONTRACTORS DECLARATION • LIC. CLASS NO. — `_DWELL. UNITS — I hereby affirm that I am licensed under-provisions of Chapter 9 ADDRESS 11,V �) 7fi°�d p, p3• (commencing with Section 7000)of Division of the Business and LIC SEWER MAP Professions Code,rand my license is in full force-and effect. CITYh 77-3 CLASSBK , q� VALIDATION r R _ �? SQ. FT. NO. OF NO.OF CHECK t3_: License Number,J+ `•t/02.E 2 Lic.Class /✓ SIZE STORIES FAMILIES ONE ,' Q - t // .VALUATION tltl / l �? Of l )S'or` NEW q Contractor lC�l��l/ c trate _� / DESCRIPTION OF WORK .wpm /1 (� � �! / 1'-7 It> ADD $ '.� V rt 0 Mpr "I am exempt under Sec. 4 �d�yt r :. �( �- q -ALTER'• (S 8.8P.C. for his reason KSO>� b� h��►� REPAIR �. $ G1r7 Date: USE OF DDEMOL EXISTING BLDG. Signature APPLICANT TEL. FINAL OWNER-BUILDER':DECLARATION ' PRINT u. . DATE I hereby'dffirrn that I am exempt from the Contractor's License gDDRESS %t5"c��-. Law for the following reason (Section 7031:5, Business and FINAL r•_ - =s: Professions Code): PRESENT BY ( - i1°�,_t aBUILDING =v)e I, as owner of the property, or my-employees with ADDRESS �) wages as their sole compensation,will do the work.and the structure is not intended or offered for sale(Section LOCALITY �'• 7044, Business and Professions Code):. MOVING TEL. . �I_t{r{_ 5 m 65 I, as owner of the pCONTRACTOR NO. roperty, am exclusively contracting ( a? 51.65 with licensed contractors to construct the project (Sec- ADDRESS tion 704 Business and Professions Code). C_ NHFI (: ='_L REQUIRED TOTAL SETBACK FROM ti 3` CONSTRUCTION LENDING AGENCY SETBACK YARD HWY PROP. LINE WIDTH �'• ,I hereby•affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDEA. t`� t ; ':^ �I i�t r Lender's Name L i�;l� �f!`€1�':16' - 7 //) Ii t,••". .' ' C _' LD MA Ref # Lender's Address P.C. Fee$ owl/c Permd-.Fee r �1 g I certify that I have read this application and state that the, L Issuohce Fee LDMA P/C# o above information is correct. I agree.to comply with all County Investigation Fee t 6 ordinances and State laws relating to building construction, Total Fee `� LDMA Perm # ." and hereby authorize representatives of this County to enter - m upon the above-mentioned property for inspection purposes. _ '��C��t•. Ct' � /� � / SEE REVERSE FOR EXPQJ*Ai0RY LAMGUAG�'{q „� Signature. App icant or Agent Date wj :yj G1 crl COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING q DRESS BUILDIN ADDR SS - I hereby affirm that1-have a certificate of consent to self.insure,; or certificate of Workers' Compensation Insurance,ora certified copy thereof(Sec.,3800,Lab.C.) CITY ZIP LOCALITY PolicyrNo. Company SIZE OF LOT,r NO.OF BLDGS.NOW,ON LOT ❑ Certified copy is hereby furnished. - NEAREST CROSS ST. ❑ Certified copy is filed with the county buildinginspection' TRACT BLOCK -' - LOT NO. department: - - USE ZONE MAP NO. Date Applicant ASSESSOR MAP,BOOK - PAGE PARCEL _ .,- ,: -SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM•WORKERS' OWNER- TEL NO. COMPENSATION INSURANCE WITHIN 1000 FT._OF SCHOOL? YES NO (This section need not be completed if the permit is.for-one hundred ADDRESS - •` ,v/ - DISTRICT G P O I Y - • dollars.($100)or less.) CITY _ ZIP. ROU -TYP CONST. FRE ZONE PROCESSED BY -. I'certify•that in the performance of the,work;for which this permit �7�(?' ��-�/ is issued I 'shalt not err play any person in any manner so as to A become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER - TEL - •STATISTICAL CLASSIFICATION - APT CONDO Date Applicant ADDRESS CLASS NO.. 10 DWELL UNITS NOTICE TO APPLICANT:, If; after making-.this Certificate of REQUIRED TOTAL SETBACK FROM EXIST - Exemption, ,you should` become, subject' to the I Workers' CONTRACTOR TEL NO. SET BACK YARD.., r HWY PROP LINE WIDTH Compensation provisions of the-Labor Code, you must forthwith ( 6�I�/ s/"/ op 7/ f FRONT comply_with such'provisions or this permit shall be.deemed revoked. ADD SS LIC:NO. P L LICENSED CONTRACTORS DECLARATION SID E CITY - - LIC.CLASS P L I'hereby affirm that 1,am licensed underprovisions of Chapter 9 Q'`F ® "'C SEWER MAP (commencing with Section,7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIEFS NO.OF FAMILIES - - Professions Code,and.rrly license ism ull force and effect NEW BK PG �- LlcensetNumber Dat Class DESCRIPTION OF WORK. ADD ❑ VALUATION - 0- Lice ]��jy OV Contractor o ALTER ❑ $ G�'o �'v r lG �. ❑1 am exempt under Sec. REPAIR. ❑ $ 0 B.&P.C.for this reason i�Q �r�E ffjQ/ DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. f URM ❑ -F f .n- Signature APPLICANT(PRINT) ,. - _FTEL NO. ;LDMA;Perm# i' Z ❑ I, as owner'of the property, or my employees with'wages as Z their.sole compensation, will do Ahe work'and the structure,is ADDRESS O not intended or offered for sale (Section 7044, Business and FINAL DATE / 0 _ F }I � _ PfOfeSSIORS Code.) WILLI THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A-HAZARDOUS MATERIAL. - _ OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE / J ❑ 1, as owner of the property, am exclusively Contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS.NFORMATION GUIDE'S FINAL BY ` licensed contractors to construct the project(Section 7044, YES❑ NO❑ r Business and Professions Code.) €U-''L WILL THE INTENDED USE OF THE BUIDUNG BY THE,APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH S '',Lf'fit f -7.qe{. CONSTRUCTION LENDING'AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)'SEE PERMITTING CHECKLIST FOR �' z GUIDELINES. _ - - •-. - • I hereby affirm that there is a construction lending agency for YES❑ No❑ I ? ? a the performance Of the Work for which this permit IS issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMDPERMITTING ' 3097, CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER_THE LOS ANGELES COUNTY CODE, ' TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. »''I'""`:"€'..5 EL' Lender's Address ;_5 :df OWNER OR AGENT — s Pm — .-- I,certify that I have read this ation and state under penalty of perjury that the a Inform is correct.I e to comply P.C..FEE - PERMIT FEE with all county Ina and State la relat' to building Q U construction eby authorize rep en s of this County '' ISSUANCE FEE to enter e abov e d p ti purposes. d a r INVESTIGATION FEE t!JO -TOTAL FEE / o Applican,,Ag- ale CJ SEE REVERSE FOR EXPLANATORY LANGUAGE