The URL can be used to link to this page

Home My Public Portal About10556 LIVE OAK AVE_Building__ APPUCAMON FOR BMLONG PERM ff COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS/ 1 hereby affirm that I have a certificate of consent to self Insure, BUITIyG S O or a certificate of Workers' Compensation Insurance,or a certified UU copy thereof(Sec 3800,Lab C) CIT11/ ZIP /� ' ` (Ll7 `"I U LOCALITY Policy No Company SIZE OF LOT�ri� � NO OF BLDGS NO y( ON LOT li �J� El Certified copy Is hereby furnished _NEAREST CROSS ST , El-Certified copy Is flied with the county budding inspection TRgGlI, /L ^ BLOCK LOT NO department ��7�LLLW11 VII o1LJ, USE ZONE MAP NO , Date Applicant ASSESSOR BOOK PAG PARCEL 1`Ln b � SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' W E / TEL N COMPENSATION INSURANCE qgR� g �' WITHIN 1000 FT OF SCHOOL? YES No (This section need not be completed If the permit Is for one hundred A y�(j�SilC� (� �U DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars($100)or less) V VV V I certify that in the performance of the work for which this permit CITY ' ZIP is Issued, I shall not employ any person In any manner so as to (� becOe S j the Workers'Compensation Laws RC TEC OR NGIN ER i L NO L,J !Y�w\ L�j\ t STATISTICAL CLASSIFICATION 1 Date Applicant �l/V Ul ICY �{IJC� J ADDR S CLASS NO DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate ofmLil I� REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject to the Workers' P�NTR CTO ` TE NO SET BACK YARD HWY PROP LINE WIDTH Compensation,provisions of the,Labor•Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked A�'ES• L' ��LICENSED CONTRACTORS DECLARATION P�v "1`CSIDE CLIC C S P_L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQA NO OF TIES NO OF F ILIES Professions Code, rmy ce e Is in full force ap�i eff c O1` -il_ NEW BK PG D } License Nu ber , I LIC CIBSS ( DESCRIPTI NOF WOR ADD ❑ VALUATION O Contractor ate I ALTER ❑ �J/+ O0� V ❑ lam exempt under Sec /O REPAIR ❑ 0 B&PC for this reason DEMOL ❑ LDMA P/C# W Date USE OF EXISTINO BLDG r"Y URM ' ❑ �. a- Signature P ICADFF(PRI T) XJ T NO LDMA Perm#, ACCT Z ❑ ],,as owner of the,property, or my employees with wages as o Z their sole compensation, will do the work and the structure Is AD S K- / / O 3=07 not Intended or offered for sale (Section 7044, Business and NC tC V ' - FINAL DATE a ITG Professions Code) `�� 'A3 WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ` 1> _ OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J T ❑ I, as owner of the property, am exclusively contracting with ,AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY T'`i�� 17 m 90 licensed contractors to construct the project (Section 7044, YES❑ No❑ °, 111.911 Business and Professions Code) CHECK WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 1-tlAl1(_C • .I 0 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR fll SllVG GUIDELINES I hereby affirm that there Is a construction lending agency for YES❑ No❑ Fig) the performance of the work for which this permit Is Issued(Sec3097,CIV C) I HAVE HEAD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 1(r l� 1 .1I 12/9 7_ CHECKUST-1 UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUSzi _{(�tCrlLender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMrr FROM THE SCAQMD 96637 1 A I ILoLender's AddressavNeR oR AcenT o I certify that I have read this application and state under penalty 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 co construction, and hereby authorize representatives of this County ISSUANCE FEE ato enter upo tie-mentioned property for inspect rp ses m INVESTIGATION FEE TOTAL FEE / f� CJ SEE REVERSE FOR EXPLANATORY LANGUAGE 'WORKERS' COMPENSATION DECLARATION M irrure,or a certificate of Workers' Compensation consent Isurance, or a tertified copy thereof (Sec 3800, Lab C ) Polk No'IZ�-3�z9_y COUNT.Y'OF LOS ANGELES BUILDING AND SAFETY y' Company 7Tilt� F�1.',� ❑ Certified copy is hereby furnished /05-5-6 FOR"APPLICANT TO FILL IN LiV� BUILDING, BUILDIN �-.��y ADDRESS -® Certified copy is filed with the coun building in c- ADDRESS�3-i 6 '�� ~j S G- LI Vi= OAA--- A-e tion department ' Date Applica V aTY�Evi^ l.E (,i zip G'it?QUO LOCALITY 1 NO OF BLDGS NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT S NOW ON LOT CROSS ST /h'l,_ fly COMPENSATION INSURANCE �1 ASSESSOR J (This section need not be completed if the permit is for one TRACT Sq d+- BLOCK LOT NO MAP BOOK �fo PAG6� Z• PARCE Oo�� hundred.dollars ($100)or less ) TEL _ OWNER - S �� NO U I55USE ZONE MAP o2 y 1 certify that in the performance of the work for which this / SPECIAL / _ } permit is issued; I shall not employ any person in any manner ADDRESS lAlE ��OS �! CONDITIONS i1 so as to become subject to the Workers' Compensation Laws A. Q CITY S riM'01la ZIP Oa U Date Applicant ARCHITECT OR TEL �4, GI-ION NO 39u DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO,APPLICANT If, after making this Certificate of ENGINEER �S3 CONST NE Exemption, you, should become subject to the Workers' �J j/ o U Compensation provisions of the Labor Code, you must forth- ADDRESS ST SA�A Y►1oN1 �6 -� ✓ 0J d with.comply with such provisions or this permit- shall be j TEL. STATISTICAL CLASSIFICATION APT CONDO N deemed revoked CONTRACTOR !� . NO - Z LICENSED CONTRACTORS DECLARATIONLIC p CLASS NO DWELL UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS d �701f 70 (commencing with Section 7000)of Division 3 of the Business LIC SEWER MAP p and Professions Code,and my license is in full force and effect CITY CLASS 5 BK PG �f VALIDATION �� SQ'F• /`-"'NO OF NO OF ; CHECK License Number ((ff Lic Class / SIZE 2 I t� STORIES FAMILIES ONE VALU TION 7 0.^/ �� DESCRIPTION OF WORK � NEW ❑ - X O. Contractor Date ❑I am exempt under Sec W �, (,A4, 'D �(p � S ADD ❑ $ �O• B&P C for this reason ALTER El $ t"REPAIR ❑ Date USE OF EXISTING BLDG PIA DEMOL ❑ Signature APPLICANT _ OWNER-BUILDER DECLARATION (PRINT) rc(L CV_ JA&) LA-,Ee ,NOL j, Z iS'✓� FINAL I hereby affirm that I am exempt from the Contractor's License ' Law for the following reason (Section 7031 5, Business and ADDRESS S 'lP�"�`� �ILo�' DATE L-�'- FINAL 1 Professions Code) ' ❑ PRESENT DRS A B Y+;t i•r"y },`^`_ L_v1, as owner of the property, or. my employees with BUILDING DSAC •i wages as their sole compensation,will do'the work and �., dy '- c• �� ' ' -T,3307- -, _ p�{ry the structure is not intended or offered for sale(Section LOCALITY f ?�1�� *t'.i T,3307 i8M,72 7044, Business and Professions Code ) MOVING TEL- 1, EL D�`� "'/ "3 �• - '' _ ❑ 1, as owner of the property, am exclusively contracting CONTRACTOR - NC _ b �- � t' . -:.tt+ � ' .! _ ��_., .,b_._.,,..,,t _ '°:'•`:;i._ ;_ .. �p�� W ith licensed contractors to construct the project (Sec- ADDRESS �' \ i f" r TATAL IBM.y. 2 ton 7044, Business and Professions'Code REQUIRED 1 '7 'TOTALS FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK YARD' HWY PROP LINE WIDTH l hereby affirm that there is a construction lending agency for FRONTa• ��. the performance of the work for which this permit is issued P L � �' (Sec 3097, Civ C ) SIDEc- P L Lender's Name 01 11/24/92 9 LDMA Ref ii PC Fee$ Permit Fee V f- / - Lender's Address ' 16!82 1 A91C10.5•_+ o I certify that I have read this application and state that the Issuance Fee`"� ' 7� 1.DMA-P/C N above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to wilding construction, Total Fee LDMA Perm N and hereby au orize -presentativ o this County to enter upon �ae-me o ed proper y f r inspection purses f� a I v SEE REVERSE FOR EXPLANATORY LANGUAGE 'Vn1 ignature of Applicants r Agen e