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HomeMy Public PortalAbout9515 LA ROSA DR_Building__ WORKERS' COMPENSATION DECLARATION i�, reb;* r I have. certificate of consent to Self sure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR WILDING PERMIT or a certified*opy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY. Policy No. Company BUILDING ❑ .Certified copy is hereby furnished. . FOR APPLICANT TO FILL IN _ ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS V(, CITY C� ZIP C1 17&0 LOCALITY Date Applicant NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF. LOT J? NOW.ON LOT �. CROSS ST. COMPENSATION INSURANCE /� i ASSESSOR p /► (This section need not be completed if the permit is for one TRACT 36 3 BLOCK LOT NO. 15 MAP BOOK 0 (/ PAGE V PARCEL �Q� hundred dollars ($100) or less.) jj TEL. USE ZONE MAP OWNER v(� 1 bei 1 is BV( NO.� NO. I certify that in the'performance of the work for which this ./� SPECIAL >_ permit is issued,'I shall not emplo my person 'n any manner ADDRESS 4.Q) ,`v YI VC, CONDITIONS a so as to become subject to the W ers' Com alio Laws. ! O ] CITY � !� 61'� zip L 1780 v Date 1_Applicant ARCHITECT OR ITEL. W NOTICE TO APPLICANT: If, after m g this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE P CESSED BY Q Exemption, you .should become s lett to the Workers' ptr! CONST.-1/ NE U Compensation provisions of the Labor Code, you must forth- ADDRESS Y "' CL N with comply with such provisions or this permit shall beTEL. STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked. CONTRACTOR "t- NO. Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. / DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC: and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT NO. OF NO. OF CHECK License Number Lic. Class SIZE K, STORIES FAMILIES ONE ti°, •i =3 VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ /�i �1 �j /� `' T 1 ADD , T "f�; El am exempt under Sec. UY YYl ' yy t9 S HEN' ALTER ❑ u - B.BP.C. for this reason Y6 � REPAIR [:] $ )(-`s I#` 6 i Date: SE OF 3;EMOL ❑ h,WC ( )EXISTING BLDG. ED! ,•rt Signature APPLICANT -i,fi;j (PRINT) u Q�GtCO. FINAL ��� +_Ilt9::3C OWNER-BUILDER DECLARATION DATE f I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By 0 i 3 113 =' BUILDING _,-,- H••, I, as owner of the property, or my employees with ADDRESS • ..r..v lit t �F 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. w'']' CONTRACTOR NO. ❑ I, as owner of the property, am exclusively contracting < T'.�'+'" with licensed contractors to construct the project (Sec- `'I°" ADDRESS is_y tion 7044, Business and Professions Code.) -tea:� , �•_` )U 1�-iL 204 = 42 REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK 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. 3t (Sec. 3097, Civ. C.). SIDE t Hitt „! P.L. Lender's Name, P.C. Fee$ Permit Fee E LDMA Ref. # +. C., Lender's Address @ Z 'Lit 3.: " _ „ : •, : . 62- 0 poll 1 certify that I have read this application and state that the Issuance Fee ��• LDMA P/C# , above information is correct. I agree to comply with all County Investigation Fee 8 ordinances and State laws relating to building construction, Total Fee G-lJ`T '�� LDMA Perm. # and Weby authorize repre entatives of this County to enter m upo above-menti ne perty for inspection purposes. a _ � SEE REVERSE FOR EXPLANATORY'LANGUAGE Signal f Applicant or Agent Date ``DEPARTM'i _ "°;-_.. b AND SAFETY APPLICATION FOR PERMIT _-OUNTY OF LOS ANGELES p ' ® � 1 WM. J. FOX, CHIEF ENGINEER FOR APPLICANT `TO FILL IN FOR OFFICE USE ONLY BUILDING l� / / .'� �(�j DISTRICT NO. PLAN CK. NO. / PERMIT NO . ADDRESS LOCALITY RECEIVED BY DATE OF APPL. fDATE ISSUED NEAREST / !✓� ��� �� �� ��� G ®. Cid'_`�� `� _RROSS OSS ST. �f J�J�/,/y BUILDINGS OWNER !(/.�j..,�., I�" GS�� ADDRESS Q MAIL ADDRESS LOCALITY ��%/ ey i. �} �;F �� '-�L.' F�7.�'�/ NEAREST -- IV TEL. CROSS ST. � -��z^.-'� '.i� CITY _� .,.�. NO. p' FIRE NO.OF TYPE GROUP ARCHITECT OR y .TEL. ZONE I PLANS I I , ENGINEER /A .r1.?-Tdii7,2 NO. BLDG. -` Q y� e�ORD�.yNO. ADDRESS SETBACK LINE TEL. APPROVED CONTRACTOR I NO. BY DATE USE � APPROVED ADDRESS ZONE l ® BY DATE LEGAL CORRECTIONS DESCRIPTION LOT NO BLOCK TRACT did GS /�/ �1�' `�•I -�� 8 94" NO. OF BLDGB. / SIZE OF LOT L1 i NOW ON LOT ' USE OF / �, a I NO.OF / I NO. OF EXISTING BLDG. (�l�"® FAMILIES ROOMS DESCRIPTION OF WORK NEW ALTERATION ADDITION O. REPAIR { MOVING DEMOLISH o BE;.IZ �. /� ROOM8 STORIES - Z 512E D r WALL /f COVERINI34 ­ � !t �p I COVERING USE OF N BUILDING EW i v I 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION, INSPECTOR DATE AND AGREE TO COMPLY WITHOo .ALL COUNTY ORDINANCES FORMS, MATERIALS _ � ' ') AND STATE LAWS REGULATING BUILDING CONSTRUCTION. FRAME: FIRE STOPS, 5a SIGNATURE OF OWNER ! BRACING, BOLTS AUTHORIZED AG < �+jdt////(ID' LATH, INT.: LATH, EXT.: P. C. S PLASTER, INT. FEE I PLASTER, EXT. S VALUATION FEE FINAL S U-45 DBD MEN-T OF ,BUILDING AND SAFETY -� APPLICATION FOR PERMIT COUNTY OF LOS ANGELES1,4946 BUILDING WM. J. FOX, CHIEF ENGINEER FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY ,,rr� L(.. � DISTRICT NO. PLAN CK. NO. PERMIT NO. BUILDING "y ADDRESS t%:'("At;'r. LOCALITY - �. ' RECEIVED BY DATE OF APtP}L. DAT TISSUED NEARESST. �v :'�i"Ln. f-C �.. 4" /J ID �S 1��, 7'� 4 CROSS y v {� OWNER '4.._�`„t'vY'yv"' -1 (`n 6 ADDRESS J /O��.dy. �t�ng�10 JCiT�� R7 p ADDRESS MAIL -)14� c �A;=y\, �j = LOCALITY moo IL /@ nG NEAREST CITY ^� "-�' � � NOLO �j}( 7 CROSS ST. F'�f ARCHITECT OR TEL. ZONE I PFIRE LANS TYPE I GROUP ENGINEER NO. dI BLDG. _ S ^ ORD. NO. ADDRESS SETBACK LINE Y�l bC3 APPROVED �� p TEL. BY DATE CONTRACTOR ��\ NO. USE� _ APPROVED�� c /$ ADDRESS ZONE `/ BY - ��'%;l(k°yDATE J LEGAL ✓y� CORRECTIONS DESCRIPTION LOT NO. F, BLOCK TRACT ' S'LP 1_4 oNO. OF BLDGS. SIZE OF LOT �7 1 V7 NOW 13 LOT USE OF I NO.OF I NO. OF . EXISTING BLDG. FAMILIES ROOMS DESCRIPTION OF WORK NEW 'ALTER ATIONADDITION O A REPAIR MOVING DEMOLISH - p SQ Ij FT. NO.OF L I D SIZE ` 6a ROOMS 1 ST IES r WALL ( ROOF COVERING i COVERING USE OF NEW BUILDING -' APPROVALS I HEREBY ACKNOWLEDGE THAT' I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION, - PECTOR DATE MATERIALS AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS, Wy"T V AND STATE LAWS REGULATING BUILDING CONSTRUCTION. FRAME: FIRE STOPS, BRACING, BOLTS SIGNATURE OF // LATH, / p OWNER INT.: AUTHORIZED AO LATH, EXT.: qq•�� pp�� p� P. C. !$ ,� PLASTER, INT. FEE �y'ppp 0 ,PLASTER, EXT. VALUATION FEE ��1 Y/ FINAL �;• 'WORKERS' COMPENSATION DECLARATION ,1'•F ereby;affirm that I have a certificate of consent to self insure, or'a•certificate of Workers' Compensation Insurance, APPLICATION FOR .BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDINGAND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS � /,57 O ^ ❑ Certified copy is filed with the county building inspec- BUILDING Lot tion department. ADDRESS /I� L-�7 9,5-a �0k Date Applicant CITY Y1t le l ZIP -D � LOCALITY >p �' CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT NEARESCROSSST. COMPENSATION INSURANCE (This section need not-be completed if The permit is for one - - ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK /' j LOT NO.EL. // MAP BOOK PAGE PARCEL OWNER '`� V �E diG7Cl NO. USE ONE MAP I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in'any manner / SPECIAL so as to become subject to the Work Compensati Laws. ADDRESS / !///�✓ f� CONDITIONS 1 CITY ' ernt C(/ ZIP .` 1 7V _ 09 U Date Applicant ARCHITECT OR TEL. O NOTICE TO APPLICANT: If, after making t} Certificate of DISTRICT GROUP TYPE FIRE PROCESSED BY- J ENGINEER NO. CON ZONE Exemption, you should become subject to •the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS ST.__ 3 - with comply with such provisions or This permit shall be L. STATISTICAL CLASSIFICATION APT. JJONDO. deemed revoked. CONTRACTOR AA NO. LICENSED CONTRACTORS DECLARATION / LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am.licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC: SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK PG - VALIDATION SQ. FT. NO.OF NO. OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE / VALUATION Contractor Date DESCRIPTION OF WORK ki 1�i[ l - NEW O a 0� ❑ I am exempt under Seca /vt Qom• f n Maj , ALTER B.BP.C. for this reason REPAIR ❑ $ Date: USE OF J��JI GloP" J�rI- DEMOL EXISTING BLDG. ❑ Signature APP(CANT) e)MW C v �r �/ NO. G�. FINAL OWNER-BUILDER DECLARATION DATE /�!; ti I hereby affirm that I am exempt from the Contractor's Licensel Law for the following reason (Section 7031.5, Business and ADDRESSq,5_1 `7 FINA ` Professions Code): PRESENT BY I BUILDING 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, as owner of the.property, am exclusively contracting CONTRACTOR NO. 9 5.1 1.0 A with licensed contractors to construct-'the'project•(Sec- ADDRESS tion 7044, Business and Professions Code). _ REQUIRED . .TOTAL SETBACK FROM I _ � o _® 4O 50 CONSTRUCTION LENDING AGENCY SET BACK YARD' " HWY PROP. LINE WIDTHo 0 0 4 Q 5 0 U hereby affirm that There is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. - Q ],2 3_8 6 (Sec. 3097, Civ. C.). SIDE P.L. 5 Lender's Name LDMA Ref. # i Lender's Address P.C. Fee$ - Permit Fee— _ I certify that I have read This application and state that the Issuance Fee ,J V LDMA P/C# a above information is correct. 1 agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee LDMA Perm. # v and hereby authorize representatives of this County to enter m upon a above-mentio d property for inspection purposes. a -92 SEE REVERSE FOR EXPLANATORY LANGUAGE SignotSre OX ppli2 nt or Agent Date " ' WORKERS' COMPENSATION DECLARATION I herebaffirm that I have a certificate of cons@nt to sell; ;insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING P E RMI1 or a certified copy thereof (Sec. 3809, Lab. C_) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. - C6mpany ❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING PY Y ADDRESS , 1Oj ❑ Certified copy is filed with the county building inspec- BUILDING CJ 1 t; / os� ql tion department. ADDRESS !✓ G^ Y�JJ J Date Applicant CITY' e r1'///le, Ct;(� . ZIP � 6 17 LOCALITY (�Yl � /'41JJ it 1 NO. OF CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT l7 X '2 NOW ON LOTS NEAREST CROSS ST. COMPENSATION INSURANCE ASSESSOR SC /� (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK 45- PAGE14 1 PARCI a i hundred dollars ($100) or less.) TEL' USE ZON MAP OWNER V�(/ NO. © NO. I certify that in the performance of the work for which this permit is iss�ecl, I shall not employ any person in an manner ADDRESS j �O d� SPECIAL a CONDITIONS so as to become subject to the W ers'Compens 'on Laws. --+ / O CITY / eta►-I GG C� r ZIP 1 �/ Date 3 U 9 1 Applicant ARCHITECT OR TEL. W NOTICE TO APPLICANT: If, after makin this C rtificote of ENGINEER NO DISTRICT GROUP TYPE FIRE PROQS D BY (/ 2 CONST../'' ZONE O Exemption, you should become sub" ct to the Workers' x ) . U W Compensation.provisions of the Labor Code, you must forth- ADDRESS IJ ✓ _� d with comply with such provisions or this permit shall be TEL. STATISTICAL CLA IFICATION AP ro 0. N �WWEJQ ? deemed revoked. CONTRACTOR NO. 1 LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NCO. SEWERMAP(commencing with Section 7000)of Division 3 of the Business CLASS �)� ) VALIDATION and Professions Code,and my license effect.is in full force and eect. CITY BK. L PG. I V�/ SQ. FT. �p pp NO. OF 7 NO. OF CHECK License Number Lic. Class SIZE J 0 0 STORIES 1 FAMILIES O ONE ���� � VALUATION Contractor Date DESCRIPTION OF WORK tom(, NEW a .oV�6��0 El am exempt under Sec. X Q IY UI Y ADD F-1a , ALTER ❑ B.&P.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT W 6 TEL. FINAL PRINT q OWNER-BUILDER DECLARATION ( 7 ✓ U/ NO. 3 DATE 2 I hereby affirm that I am exempt from the Contractor's License rit / /' s;11.7 ; v Law for the following reason (Section 7031.5, Business and ADDRESS"( C/ cA FINAL ''`"�=` rof ssions Code): PRESENT - By X 1, as owner of theproperty, or m em to employees with BUILDING Y P Y ADDRESS —� wages as their sole compensation,will do the work and TOTAL 16Z ® 68 the structure is not intended or offered for sale(Section LOCALITY '! i L� 7044, Business and Professions Code.) MOVING TEL. , 4. �.r� 1L7* n V_7 I, as owner of the property, am exclusively contracting CONTRACTOR NO. CHANGE with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY. SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT 0000—Looi 1/61/90 the performance of the work for which this permit is issued P.L.. �iljC 1 i ['111 ��5 (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name P.C. Fee$ Permit Fee of LDMA Ref. # Lender's Address o I certify that I have read this application and state that the Issuance Fee / f� LDMA P/C# 8 above information is correct. I agree to comply with all County Investigation Fee d or' nces and State I s relating to building construction, Total Fee LDMA Perm. # a an ereby authorize epresentatives of this County to enter 467 the above-mea ed o e p inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ie of Applicant or Agent Date—ate WORKERS' COMPENSATION DECLARATION, I heregy affirm that I have a certificate of consent to self v insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or a'certified copy'thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No, Company~ 7-7 i BUILDING El Certified ` Ao ���1� Certified copy is hereby furnished. . ,. FOR APPLICANT TO FILL IN AR � ❑ Certified copy-is filed with the county building inspec- BUILDING tion department.. ADDRESS (/�, /fit/1 I/// �) Date Applicant CITY GWI ^'- �/ ZIP ' Gf LOCALITY e,W IC, CL PP it NO. OF BLDGS. NEAREST 1 CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE,OF LOT � L�« J NOW ON LOT CROSS T. ✓11" if' C 1 f ' ! COMPENSATION INSURANCE /`y ASSESSOR J /q /�i (This section need not be completed if the permit is for one TRACT 1 ? 6 2.V BLOCK LOT NO. MAP BOOK J (J PAGE (/Y PARCEL )o hundred dollar's ($100) or less.) TEL. OWNER YIr,�A NO. �"' US ON MAP I certify,that in the performance of the.work for which This } NO. permit is issued, I shall not emplo ny person i ny manner ADDRESS 6, I ►/'6 VV' CONDITIONS SPECIAL - d so as to become subject To the kers Comp tion Law V_" I / Q O a�PCITY Y Pi [' ZIP P �V a U ine Date Apl: A ARCHITECT OR TEL. DISTRICT I GROUP TYPE FIREROCESS BY 0 0 NOTICE TO APPLICANT: If, after mdying This Certificate of ENGINEER NO. CONST E( Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESSi a with comply with such provisions or this permit shall be TEL. STATISTICAL CLAS FICATION APT. CONDO. Z deemed revoked. CONTRACTO wOQ NO. 1 LICENSED CONTRACTORS-DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS BK PG Ql1 VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic. Class SIZE YD STORIES FAMILIES 0. ONE ❑ VALUATION Contractor Date DESCRIPTION OF WORK ^v/I NEW E a` e ADD ❑ ► El am exempt under Sec. '54 ALTER ❑ B.BP.C. for this reason U1 REPAIR ❑ $ Date: List OF DEMOL EXISTING BLDG. yQJ Signature APPLI CANT� e � TEL. ,�n FINAL OWNER-BUILDER DECLARATION NO. .W f ! DATE I hereby affirm that I am exempt from the Contractor's*License ADDRESS ! 1 � Law for The following reason (Section 7031.5, Business and - FINAL 1 rof ssions Code): PRESENT By t>•; a BUILDING :'1�-"'�(ere' I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and 33077ta,t a Vil the structure is not intended or offered for sale(Section LOCALITY POlhf 7044, Business and Professions Code.) MOVING TEL. j 1IMS ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. TOTAL I IT # with licensed contractors to construct the project (Sec- ADDRESS i L. tion 7.044, Business and Professions Code..) CHECK. 8_n0{(; REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT CHANGE CIA the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ: C.). SIDE P.L. Lender's Name 011.1 DO J01 Ii'D�."'!; m �® LDMA Ref. # '' a P.C. Fee$ Permit Fee 86 s Ar 10=27'f 3 Lender's Address O , I certify that I have read this application and state that the Issuance Fee 13, LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee p p 8 a din ces and Slate laws relating to building construction, Total Fee LDMA Perm. # < and reby authori representatives of this County to enter up a above-m boned roe ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . Signe re of Applicant or Agent - Date y WORT ES'.,COMPENS,IJION DECLARATION �•,I he;ebyf affirm, nat I'have a certificate of consent•to self insure, o}a ce;t;ficate ul Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or-a certified copy thereof (Sec. 3800, Lab. C.) . COUNTY OF LOS ANGELES BUILDING AND SAFETY y PQFOR APPLICANT TO FILL INolicy No. Company , Certified copy is hereby furnished. BUILDING' ADDRESS Ceriified copy is filed with'the county building lnspec- BUILDING , Tion department. ADDRESS a$•� �� G Date Applicant CITY Y11 Q, C1 �\ ZIP —( l LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' ' N07 OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT 2 CROSS ST. (This section need not be completed if the permit is for,one : — ASSESSOR fxundred dollars ($100)or less.) TRACT BLOCK L07 NO. MAP BOOK PAGE PARCEL TEL. USE ZONE &SPE certify that in the performance of the work for which this OWNER NO.permit is issued, I shall not employ a persori in an manner _ �so as To become subject to the Wor rs'Compens ion Laws. ADDRESS �GI $ y lONS U CITY _ ZIP . Daie Applicant ARCHITECT OR TEL. DISTRICT _ GROUP TYPE FIRE PR ES ED BY NOTICE TO A PLICANT: If, after akin his ertificate of ENGINEER NO. F Exemption, you should become subject to the Workers' L CONST1. / ZONE Compensation provisions of the Labor'Code, you must forth- ADDRESS J 1 �3 V IL with comply with such provisions or•this;*permit shall be' TEL. STATISTICALCLASS IFCATION APT. NDO. deemed revoked. CONTRACTOR l/�/ IV NO. LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS I hereby affirm That I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effe& CITY CLASS BK_4 f VALIDATION SQ. FT. NO.OF NO. OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VAL ATIO DESCRIPTION OF WORK'4,4d NEW-- C] // Contractor Date / ADD $ -/, V I am exempt under Sec. rQ9Y�1 C1C6ef et- .l01 +j ❑ , J )) ALTER B.&P.C. for this reason W L✓IdI(AO VJGIt✓K v1S REPAIR- ❑ 3- USE OF Date: {� EXISTING BLDG. (G will Ou�z DEMOL ❑ APPLICANT TEL. Signature f p FINAL o OWNER-BUILDER DECLARATION PRINT V�uG '1 NO.�p�'�03�I DATE.. , 6 6 3,9 A I hereby affirm that I am exempt from the Contractor's License QJ /1� ) _ �� # 0 0 0 0 0.� Law for the following reason (Section 7031.5, Business and ADDRESS 11 K/1 ^ �, FINAL Professions Code): PRESENT BY BUILDING I o2 8 I, as owner of the property, ormy employees with ADDRESS wages as their sole compensation,will do the work and , o o 1 2 IL,8 8= the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL.- CONTRACTOR NO. 03.09-87. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project*(Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY SET�BACKD YARD HWY TOT4PROP.SETBLINECK FROM WIDTH I hereby affirmthat 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.). SIDE P.L. Lender's Name / 2 G LDMA Ref. # Permit Fee - Lender's Address P.C. Fee$ t I certify that I have read this application and state that the Issuance-Fee ,5 (/ LP%C# above information is correct. I agree to comply with all County Investigation Fee Cj`6 ordino es and State laws relating to building construction, Total-fee o LDMA Perm. # and h eby authorize presentatives of this County to enter m upon a above-me __ed property for inspection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE • O� Sig -f re of Applicant or Agent 'Date a'VjIORMeERS'.COMPENSATION DECLARATION , :, su reby�'.afflrm that I Fcertificate of consent to self - APPLICATION FOR BUILDING PERMIT insure, � � re, or a ce°tificate off Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lob.•C.) " COUNTY OF,LOS ANGELES BUILDING ANDS SAFETY Policy No. Company : BUILDING 1 '0/ ff ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS - J� Certified copy is filed with the county building inspec- BUILDING 'tion department: - ADDRESS O V-I VPr Date Applicant CITY f f ZIP vv LOCALITY "CERTIFICATE OF EXEMPTION FROM-WORKERS' NE). OF..BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if-the perm it'is for'one ASSESSOR hundred dollars ($100)or less..) TRACT BLOCK LOT NO. MAP'BOOK' PAGE PARCEL - TEL, USE Z NE' MAP certify that,in the performance of the work for which this OWNER V NO. / � NO. ;y. permit is issued, I shall not employ any person in any manner hCG SPECIAL so os,to become subject to the Work s'Compens on laws. ADDRESS- CONDITIONS O V CITY e ZIP.. Date Applicant ARCHITECT OR TEL. O NOTICE TO"APPLICANT: If, after makin is Cerhficdte of DISTRICT. G UP TYPE FIRE PRO SSED BY ENGINEER NO. Ehemptiori,',you should become subject to The Workers' CONST. ZONE V Compensation provisions of the labor Code; you must forth- ADDRESS / V ch. with comply with'such provisions,or. This permit shall be -- - g f�,.,,Q TEL. STATISTICAL CLASSIFICATION APT. CO O. deemed revoked..•,_,, CONTRACTOR �/LN Ilk' NO. _ LICENSED CONTRACTORS DECLARATION - - - - --• - -- LIC. CLASS NO. DWELL. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and _. LIC.- SEWER MAP Professions Code, and my license is'in full force and effect. CITY CLASS _,. gK. PG. 1 VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic.Class SIZE _STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW El ADD ❑ a oco, 0,0 ❑ I am exempt under Sec.. Le40LTER ❑ $ , B.&P.C. for this reason EPAIR Date: EXISTING BLDG. )h y., -� DEMOL ❑ „ _ /-j/�} APPLICANT _n _ .. TEL _ �G C 7 Signature FINAL _ OWNER-BUILDER DECLARATION PRINT) NO. "2o37 DATE, i I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business*and ADDRESS FIN Professions Code): PRESENT BY „ '• BUILDING 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. - '' T' ;2 7 4 5,*8-A . I, as owner of the property, am exclusively contracting CONTRACTOR NO # o 0 0'o'' - with licensed contractors to'construct the project'(Sec ADDRESS tion 7044, Business and Professions Code). o o 4,Q 5 0 REQUIRED TOTAL SETBACK FROM XIST. _ - CONSTRUCTION LENDING AGENCY SET BACK --YARD HWY' PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT o 6 a 4 0.5.0 0 the performance of the work for which this permit is issued P.L. - =- (Sec. 3097, Civ. C.). SIDE 0 Z 1 3 d 8 7 ' _ P.L.__... _. Lender's Name - g LDMA Ref. # .. _. P.C. Fee$ _. .. .. .. Permit Fee Lender's'Address I.certify that I have read this application and state that the Issuance Fee -V, V- -LDMA P/C# a above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating To building construction, _ _ ... ..._ Total Fee LDMA Perm. #- u and her by authorize representatives of this County to enter upon t above-mentio d property for inspection purposes. 2�✓ O _ _. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign eof App icon orrAgent - - Date - - - Oi