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HomeMy Public PortalAbout10552 LIVE OAK AVE_Building__ t WORMERS' COMPENSATION DECLARATION insure, oraa i)rtif cate of Worke s'.Comcertificate pensat on consent Insuran elf lQG p d O KGOO G°�.- o M d D �l 'PERM,Q�TU or,a Vrtified copy thereof (Sec 3800, lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Polcy',iVo'12Z3�2ci^91 Company_>7 �uruD _ " ❑ BUILDING Certified copy is hereby furnished FOR L T TO ILL ADDRESS ® Certified co is filed with the coup buildin ms ec BUILDING PY 9' P ADDRESS s' 1 V� L--1 vE OAS-° tA�/ . tion department. CiTY-T • L-e Cil 2tj zip 780 LOCALITY -Tr=v- LE U Date Applicant -5-791 NO OF BLDGS NEAREST T' CERTIFICATE OF EXEMPTIO FROM WORKERS' SIZE OF LOT NOW ON LOT O CROSS ST /�l� Ned } COMPENSATION INSURANCE ASSESSOR (This (This section need not be completed if the permit is for one TRACT q 1qZ BLOCK LOT NO On MAP BOOK; 0.��(p, PAGE �� PARCEL hundred dollars ($100)'or less ) An TEL OWNER �i"TA�S INCL pt's NO 6 1513j 7 USE ZONEOP I certify that in the performance of the work for which thisSPECIAL' of ", a permit is issued, I shall not employ any.person in any manner ADDRESS q4 S 'FLQwE~ ��hoS / CONDITIONS so as to become subject to,the Workers'Compensation LawsO CITY LOS AP3(a G LAS ZIP 900 1 U Date Applicant ARCHITECT OR - TEL DISTRICT GROUP TYPE FIRE PROCESSED BY W NOTICE JO APPLICANT If, after"making this Certificate of ENGINEER C.1-EUI••JG- NOZ- R % CONST ZONE 0 Exemption, -you should become subject to the Workers' NbC ��O U Compensation provisions of the Labor Code, you must forth- ADDRESS i4 S.4 • &-rk. 'S? 5.!'sW-rA MON / O V Od 0- with with comply with such provisions or this permit shall be TEL G/ STATISTICAL CLASSIFICATION NDO N deemed revoked. CONTRACTOR NO J �D90 Z o L CLASS NO DWELL UNITS-Z-77 LICENSED CONTRACTORS DECLARATION ADDRESS D 3 Nom- I hereby affirm that I am licensed under provisions�of Chapter 9 7D471SEWER MAP ; _(commencing with Section 7000)of Division 3•of•the BusinessLIC h��/ ��ta�J/EL LI ASS and Professions Code,and my license is in full force and effect CITY BK PG VALIDATION SQ F�Ti NO OF NO OF CHECK License Number 5-70:1 1 $ Lc Class SIZE �i ��D STORIES FAMILIES ONE VALUATION Contractor �k10t" Lll l� Z 'j. DESCRIPTION OF WORK NEW ❑ /7 �� d0•� 7� 5 Date �- ADD ❑ s Od0•o-0 �� y ❑I am exempt under_Sec (o(o S ALTER ❑ B&P C for this reason REPAIR ❑ $ Date USE EXISTOING BLDG F n/r DEMOL ❑ �� APPLICANT TEL " Signature l_• FINAL(PRINT)C__ SAI/ WE NO ({) 555 2 OWNER-BUILDER DECLARATION �/ I hereby affirm that I am exempt from the Contractor's License ADDRESSl s w ' y'►v� l.J�t ,` " Law for the-followingreason, Section 7031 5, Business and -FINAL = - - Professions Code) ( PRESENT - By•< c - ACCTA +_ _ BUILDINGlam' ... El 1, as owner of the property, or my employees with ADDRESS y ,ti� 0307 18Ae72 wages as their sole compensation,will do the work and yr'a�, LOCALITY t ITEM - the structure is not intended or offered for sale(Section _ �. �-^�-ry� _ -TFL 7044, Business and Professions Code ) MOVING ❑ _ CONTRACTOR I, as owner of thePro property, am exclusively contracting % 9 � JOCA.�� •7 with licensed contractors to construct the project (Sec- ..., , _ f• L�•/y/ j ADDRESS �� ; _ iM. l� CHECK 1�o7i tion 7044, Business and Professions Code ) �- REQUIRED '- TOTAL`SETBACK'FROM " 1EXI5T+ j ( 3 CONSTRUCTION LENDING AGENCY SET BACK t YARD ( HWY PR LINEwTMr- I hereby affirm that there is a construction.lendmg agency for FRONT pt..r.},a p •J" Y} "°' "_s"'''• ' the performance of the work for which-this permit is issued P L (Sec 3097, Civ C ) SIDE �. q i• ; }'',0000-RM1 E/i �7c Lender's Name 'N Jl_ +OOSt1 1 AM 10 53 LDMA Ref #• )•- - P C Fee$ Permit Fee - - - Lender's Address ` I certify that•I have read this application and state that•the- Issuance Fee LDMA P/C# 8 above information is correct I agree to comply with all County Investigation Fee d ordinances and State jaws relating to b ing construction, Total Fee O U©• LDMA Perm # \ a a and hereby autfMrize representatives t Is County to enter {�J upon a ve/rme tion property r spection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant o gen - Date , QPPUCAMON FOR SOLONG PERMIT COUNTY OF LOS ANGELES'. ,BUILDING•AND SAFETY WORKER'S COMPENSATION'DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUIL IN , - _ I hereby affirm that I have a certificate of consent to self Insure, �i rl or a certificate of Workers' Compensation Insurance,or a certified copy thereof(Sec 3800,Lab,C) CITY /� i ,�� ZIP + LOCALITY ' Policy No " Company SIZE OF LOT ,(�� % �' NO OF BLOGS WON LOT ❑ Certified copy,IS hereby furnished "Tv� I NEAREST CROSS ST ❑ Certified copy Is filed with the county budding Inspection .TR T BLOCK LOT NO department Alt ASSESSO USE ZONE MAP NO Date Applicant A OOK PAGE PAR EL _ ' ' ✓ �, - SPECIAL CONDITIONS W E TEL NO CERTIFICATE OF EXEMPTION FROM WORKERS' / C WITHIN 1000 FT OF SCHOOLS YES NO s COMPENSATION INSURANCE _ _ _ ' • AD , (This section need not be completed If the permit is for one hundred �1 DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY, dollars,($100)or less) ' ' P, CITY ` , ZIP �.r1qD �� + I certify that In the performance of the work for which this permit _ 9TAb IS issued, I shall not employ any person In any manner�•SO as t0 qRC TEC O ENGIN ER t TE NO' I_.,. Date" 'beco je t•to the pP oraners'C. ompen t L � •! ADD E S q�' Iv STATISTICAL CLASSIFICATI01d"�L / p T • ' O �J+ l�j,,(J� I}, q'EJS w'p �//��� CLASS NO CNF✓ '7TFr {� NOTICE TO •APPLICANT If, 'after'making this Certificate'of ' ) �'1" / "VUpuREQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become Subject to 'the Workers's' TOR TEL NO ` SET BACK YARD HWY PROP,LINE WIDTH , Compensation provisions of the Labor Code, you must forthwith . . ' C�"� 1 U FRONT comply with such provisions or this permit shall be deemed revoked ADDRE S LIC NOP L LICENSED CONTRACTORS DECLARATION PILE ' CITY �/�1 LI CLAS P L I-hereby affirm that I am licensed underprovisions of Chapter 9' L/ SEWER MAP i S F NO OF ORIES• NO OF MILIES (commenting with Section 7000)of Division 3 of the Business and - 7��, ,NEW BK > PG a Professons Code n he e Is In full iea,�e_lle t V �� _ License Numbne� � Llc [JESCRIPTO OF WOR ADD ❑ VALUATIO D Q Contractori'v • Date �.� ALTER ❑ �` pee U REPAIR ❑ ❑ I am exempt under Sec B&PC for this reason DEMOL ❑ LDMA P/C# h r LU Date USE OF EXISTING'BLDG URM ❑ 1 - Signature P '(PRI` ) - T L NO - LDMA Per 1 Z ❑ I, as owner of the property,'or my'employees with wages as _ f' i their-sole compensation, will do the work and the structure Is AD �} 1� t1 ✓� �j,jt t7 ` t 1�ail not Intended or offered for sale (Section 7044, Business and C Y�•t ` FINAL DATE•- _ _ .Q If �yeI Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL i - 0 ' 1 1 1 LI S ❑ I, as'Owner Of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERWLS INFORMATION GUIDE'S - FINAL BY 5 '•[I ITAL I••$ fg, - 90- licensed contractors to construct the project (Section 7044, :-YEP EI No El � " Business and Professions Code) CHECK 117.& • WILL THE INTENDED USE OF THE'BUIDLING BY THE APPDCANT ORS FUTURE'BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH l CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR w ., CHANGE. �' o00 GUIDELINES ,�• I hereby affirm that there Is a construction lending agency for YES El NO❑ �T"���j _ N the performance Of the Work for Wt11Ch this permit IS issued.(Sec, I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING "/.Ir/ • 'y�S�(�'� { _ { [�.� 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 3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD { - 9 6A � i Ayet '7 o 54 o Lender's Address 7 - - Ill I OWNER OR AGENT O 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 ordinances and State laws relating to building construction, an ereby authorize representatives of this County ISSUANCE FEE ro -Y� to enter up ove-me Heil property for Inspeoti� 9 INVESTIGATION FEE TOTAL FEE / �y . i�.a a rwa�c o�Aee.+l i !� SEE REVERSE FOR EXPLANATORY LANGUAGE