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Home My Public Portal About10550 LIVE OAK AVE_Building__ APPUCAMON FORSULONG PERNT COUNTY OF LOS ANGELES _ BUILDING AND SAFETY , WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS f X55 yC OAV I hereby affirm that I have a certificate_of consent to self Insure, BUILDING ADDRESS ` or a certificate of Workers' Compensation Insurance,or a certified _0 U v et 404y-- copy thereof(Sec 3800,Lab C) CITY _ ZIP T ,Z�I � V("� �C>N1 v LOCALIT 1- f POMC-y NO Company�+�� SIZE OF LOT NO OF BLD S NOW ON LOTC� �—� V l�(:ertlfled copy Is hereby furnished � NEAREST CROSS T �C rtlfled copy Is filed with the county budding Inspection TRACT BLOCK LOT N de ar ent//Q -s 3q,� USE ZONE MAP NO 3 Date• ( ` `� Applicant 4t� 7N W1N� ` ASSESSOR MAP BOOK RAG PAR-.?-LL Ly �I SPECIAALL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' +./ l COMPENSATION INSURANCE QwN ��1 s tµ"•r TEL r`S WITHIN 1000 FT OF SCHOOL'? YES NO (This section need not be completed 1f the permit 1s for one hundred ADD S q��' J 7 dollars ($100)Or 1255) V(] �I SS SON �/ it— CITY GROUP TYPE CONST FIRE ZONE PROCESSED BY I certify that in the performance of the work for which this permit CITY �� w ^ zI'9I-1 -10 - 1s Issued, I shall not employ any person In any manner so as to Y ER "� .08 (L become subject to the Workers Compensation Laws ARCHITECT OR ENGINEER TEL NO' STATISTICAL CLASSIFICATION APT CONDO - Date Applicant ADDRESS CLASS NO'� DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you' should become Subject to the Workers' CONTRACTOR T LINO SET BACK ate' t�� ,� O - YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith —fp ��T �-q�0 � FRONT . comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO PL LICENSED CONTRACTORS DECLARATION 5 A(�PXL CL 0Q$ SIDE CITY LIC CLASS P L 1 hereby affirm that I am licensed underprovislons of Chapter 9 19,601V, 8EWER MAP (commencing with Section 7000)Of Division 3 of the.Business and SQ FT SIZE NO OF STORIES NO OF FAMIL S ' Professions Code,and my license is in full force effect I SQ NEW BK PG D } License Number �'rl Lic Class DESCRIPTION OF WORK ADD E] VALUATION a T�Gk �� O Contractor yt" �aµ�6te -1 �O ^' ALTER El $ ��' cc ❑ I am exempt under Sec REPAIR ❑ $ 0 B&PC for this reason DEMOL ❑ W Date USE OF EXIy�TING BLDG URM LDMA P/C# ' Signature APPLICANT(PRINT) A TEL NO LDMA Perm# '�i . `�' z_ ❑ 1, as owner of the property, or my employees with wages as � Ce NS ` Z 1 ITEM:, their sole compensation, will do the work and the structure Is ADDRESS O not intended or offered for sale (Section 7044, Business and FINAL DATE ]� Q> TOTAL .103-05 Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL [—� ..(� /• /•p,{ El 1, as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE "'I t HE K 103.115 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY licensed contractors to construct the project (Section 7044, Business and Professions Code) ves❑ N - CHANGE 00 WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH < CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR r GUIDELINES OCIM-01001. j, 7J i 1l 9? I hereby affirm that there 1s,a construction lending agency for ves 1:1 NO� • a the performance of the work for which this permit Is Issued Sec (( i {fir{{{ �}7 3097,CIV C.) p ( I HAVE READ THE HA MATERI S INFOR 10 GUIDE AND THE SCAOMD PERMITTING I3v46 1 A (11:0/ N CHECKLIST I UND T MY RE REMEN U R THE LOS ANGELES COUNTY,CODE, TITLE 2 CH yVO 220 100 GH 2 20 140 CONCERNING HAZARDOUS 3 Lender's Name MATERI AININ ERMIT FROM THE SCAOMD a Lender's Address O OWNER OR AGENT o I certify that I have read this application and state under penalty 0 of perjury that the above Information IS correct I agree to comply PC FEE PERMIT FEE N with all county rdlnances and State law relating to budding mconst n n hereby aut nze repre tives of this County ISSUANCE FEE �/ D ato e er u n e abo me oned prop for inspect n pur ses INVESTIGATION FEE TOTAL FEE ^ ure d Apps l a Agent 50, 11 SEE REVERSE FOR EXPLANATORY LANGUAGE COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION g�S FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self Insure, Bu�gfty /, 1s �� or a certificate of Workers' Compensation Insurance,or a certified 1 U 1� �/ V J�� copy thereof(Sec 3800,Lab C) CITY P1 I� ZIP /'� LOCALITY ' Policy No Company SIZE Ta, u OF BLDGSvNI WON LOT ❑ Certified Copy Is hereby furnished ` NEAREST CROSS ST ❑ Certified copy Is filed with the county building Inspection Tj"I BLOCK LOT NO USE ZONE MAP NO department Date Applicant ASSESS M1 BOOK AA I PARCEL INn SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWN �, L - � No COMPENSATION INSURANCE ��$j$-y,�Jqj�) 1� 1 1� WITHIN 1000 FT OF SCHOOLS YES No (This section need not be completed If the permit Is for one hundred Du ADDe 'W V ` �l O^� DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars($100) or less) CITY ZIP I certify that In the performance of the work for which this permit IS Issued, I shall not employ any person In any manner so as to C ECT R NG EER 7 NO !/ beco s bj c t the Workers' C�o¢mpen anon Laws 2,y/J\ ( _ STATISTICAL CLASSI(�F/l�F/jT (� END0 Date` Appllcant _7��1 �'� l� .) ADD E S �LF6 UN4 � �[ (� CLASS NO NOTICE TO APPLICANT If, after making this Certificate of 1 w REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject t0 the Workers' CO TRACTO �(�°� TE NO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith i r 6 V 1 FRONT comply with such provisions or this permit shall be deemed revokedgppRE �, �q„ J P L �1r1L {- 1 SIDE LICENSED CONTRACTORS DECLARATION CITY ( LIC(p�AS P L I hereby affirm that I am licensed underprovisions of Chapter 9 `-� v SEWER MAP (commencing with Section 7000)of Division 3 of the Business and NO OF TORIES I NO OF IMILIES Professions Code, n lice e Is In full force a effe t J NEW BK PG a License Nu be � Llc Cla s O• �1. DESC IPTION OF W RK D ❑ VALUATION D Q 14A �-0 Contractor Date A R ❑ $ DDD V IA 16 14EWcc ❑ 1 am exempt under Sec REPAIR ❑ $ 03 B&PC for this reasonkb DEMOL ❑ LOMA P/C# W Date USE OF EXISTINd BLDG 7��. URM ❑ q a_ Signature I IN ' / ,gT co N J LDMA Perm# - 1 Z ElI, as owner of the property, or mZ Al_.T y employees with wages as their sole compensation, will do the work and the structure Issr� / 0 330 j17.90 not intended or offered for sale (Section 7044, Business and (I V[V C, • FINAL DATE Q ITEMS Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL yi tr ❑ I, as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q P P y. Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE licensed contractors t0 Construct the project (Section 7044, FINAL BY TOTAL 1 17 - 90 Business and Professions Code) WILL ❑ No❑ ! t7L 117.90'7 WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING �.��•.K 1 1 f°90 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH r CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR prp��[({'� GUIDELINES 1• hiNGE I hereby affirm that there'Is a construction lending agency for YES❑ NO❑ �j rn the performance of the work for which this permit Is Issued(Sec I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING //A11 3097,Civ C) CHECKLIST I UNDERSTAND MV REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, 'I S� t 11111 �I['�(�7 5.f U —3 a TITLE 2,CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS _'(�tJl1 ��//�� V J JVv 1C IL Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD {�6�'? 1 I•5 1 o Lender's Address Cr R«AGENT W-� p 0 o I certify that I have read this application and state under penalty o Of perjury that the above Information IS correct I agree t0 comply PC FEE PERMIT FEE - o with all county ordinances and State laws relating to building a construction, and b authorize representatives of this County ISSUANCE FEE m to enter upo e-mention perty for Inspect) pur ses p?� a m 9 INVESTIGATION FEE TOTAL FEE SiW.eiure of Appl-&Agent are6. 117. SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION suurre� or aff ertif cane of Workers' Comtpensdhon Insurance, _ la P p d CAU D O N Flo 12, RIM�d O��l C� p ERN�� or a certified copy thereof (Sec 3.800, Lab C.) • j2Z3aZ9, P ' y'�_�VNID "'COUNTY OF LOS ANGELES BUILDING AND`SAFETY�' PolicyNo" Com 'a n' I��'-r� BUILDING �❑b Certified copy is hereby furnished FOR APPLICANT TO FILL IN ' ADDRESS �flSS D Uel& -Oxy- tu' Certified copy is filed with'the county building mspec- BUILDING. p s S a VE tion de artment. ADDRESS U Date tZ 2' APPlcont a �NS7 CITY LE GtT ZIP"917 T D - LOCALITY 1 t NO OF BLDGS NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 1.2.�✓ NOW ON LOT O CROSS ST eI.,YYNON?e COMPENSATION INSURANCE ASSESSOR 2► (This section need not be completed if the permit is for one TRACT 9Z.. BLOCK' LOT-NO MAP BOOK,< <j �Q PAGE Z PARCEL hundred dollars ($100)or less') _ TEL / OWNER STAP.:rr.S YL NO2t3�o Is USE ZONE NOP ( I certify that in the performance'of the work for which this ��-77 1 SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS(p-OS a V 14��• J` , �-( CONDITIONS ; O so as to-become subject to the Workers'Compensation•Laws CITY.L .O A 1,1(��(Fps ZIP O d'1 U Date Applicant ARCHITECT OR TEL .�p� DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT If, after-making this Certificate of ENGINEER Tv ��,��tQ •NO°✓�V 1 a CONST ZONE 0 Exemption, you should become subject. to the ,Workers' �� MD S•o8 R2 tj Compensation provisions of the Labor Code, you must forth- ADDRESS I $Jl.1J- A4.01� Y11 U 7 Y.., �j a with comply with such provisions or this,permtt shall be TELSTATISTICAL CLASSIFICATION APT CONDO N deemed revoked , CONTRACTOR'TE NTO" 0O W-r NO . . _ ' _ - . ( Z LICENSED CONTRACTORS DECLARATION •LIC' CLASS No- O DWELL UNITS • I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS( S' Sit V AS NO 51 (commencing with Section,7000)of Division 3 of the Business � SEWER MAP and Professions Code,and my license is imfull force and effect CITY -7t&t4 �'�`� �'� CLASS 5 BK � N Ig/tq VALIDATION 51��7 SQ FT' ' ` NO'OF NO OF CHECK �11•L_( n-'—� License,Number Lc Class SIZE 2.`iZ.s STORIES (n FAMILIES/� ONE E�C��J GO AI ST. ly q�i DESCRIPTION OF WORK Y LA.1� 4��R NEW' VALUATION -- t Contractor Date •F _117 �4 ADD ❑ $ ' 1 !TEN ❑I am exempt under-Sec _ ALTER ❑ TOTAL " ' B&P C for this reason -. REPAIR ❑ rr u sL, Date USE OF - ^^ - - - - - 4HEC�+, EXISTING BLDG /+ - DEMOL ❑ APPLICANT• + 1_ Signature (PRINT) 5-r•u1EXS INTI-O Ev NO v��lS FINAL q: MANGE aE (i OWNER-BUILDER DECLARATION DATE �'� 1'�j� �`+` - a I hereby affirm that I am exempt from the Contractor's License �UE�j f� sp LA j H .r Law for the followinc reason (Section 7031 5, Business'and ADDRESS�� s FINAL• Professions Code) PRESENT By t { ❑ DING I, as owner of the property, or my employees with ADDR SS �� t` tl a F1357 i 01L;.'J1 wages as their sole compensation,will do the work and /� �'�;t�{{1^/`�f�ff� a 9 P LOCALITY /#1 • �JtT4tTeB the structure is not intended or offered for sale Section _ 1h_)�� I 7044, Business and Professions Code) (• a MOVING TEL v r/� 3137 to7•' C. CONTRACTOR NO �// 17 t1't t ❑ j, as owner of the property, am exclusively contracting �' � ✓t �P+ with licensed contractors to construct the project (Sec- A�, _ADDRESS , ' tion 7044,,Business and Professions Code ) - � - . -. _ .,, _ •; , - �-y _� REQUIRED` '�' r TOTAL.SETBACK<FROM EXIST �' Tf1TAE ..f.080.':_t - CONSTRUCTION LENDING AGENCY SET BACK r.,YARD• HWY PROP LINE WIDTH - y.J� I hereby affirm that there is a construction lending agency forFRONT' �� ^+ t,• �, v CHECK �'fi11).�Ct the performance of'the work for which this pe�mit.is issued P L (Sec 3097, Civ'C ) SIDE CHANGE, Lender's Name ,�{{ P C Fee$ .J / Permit Fee %9�•+`�` �/ / LDMA Ref q' ,' r• 3/ 1 11 Lender's Address r !, ° j certify that I ha read this applcat n and state that the •��D1 ' Issuance Fee LDMA P/C# �+6� above infor m at iscorrec l agree t c mply with all County Investigation Fee �J / ordinances tat la relating o uilding construction, Total Fee LDMA Perm #i R and eb than r r sentat+ a of this County to enter ' on th ve- t n rope for inspectio pu poses - �Z SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent D to .