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Home My Public Portal About10558 LIVE OAK AVE_Building__ APPUCATMN FOR BULONG PIERNT COUNTY OF LOS ANGELES BUILDING AND SAFE Y - WORKER'S,COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESSp I hereby affirm that I have a certificate of consent to self-insure, B�ll(p HESS �� or a certificate of Workers' Compensation Insurance,or a certified 1U PA �oi copy thereof (Sec 3800,Lab C) CITY � tc n ZIP r 1 LOCALITY Policy No Company SIZE F NO OF BLDGS NOW N LOT ❑ Certified copy Is hereby furnished . NEAREST CROSS S ❑ Certified copy,Is filed with the county budding Inspection, TRACT] BLOCK LOT NO 1"_ department (/� � USE ZONE _ MAP NO Date Applicant ASSESSOR tQ P 1;00K - PA E PARCEL r 1 b SPECIAL CONDITIONS • CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER T,gio r COMPENSATION INSURANCE �p�pR �QS t✓�--V ' -� WITHIN 1000 FT OF SCHOOL'S YES NO (This section need not be completed If the permit Is for one hundred AyHIS%J� )� DISTRICT GROUP TYPE CONST FIRE ZONE RO SSED BY dollars($100)or less) �V"(/ w�l 1✓ CITY P-1. P�1 ZIP /' I certify that m the performance of the work for which this permit /� 1-1-10 is issued, I shall not employ any person In any manner so as to J becom u�the Workers'Compensat on L wS ARC ECT E GINSER TE NO I In ��(f ( YMllr *VI SII STATISTICAL CLASSIFICATION AP CON Date �� Applicant ,J•�V I i �O K ADDRE S 'O�-��1 CLASS NO DWEL I NOTICE TO 'APPLICANT If, after making this Certificate of vv REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become ,subject to the Workers C NT CTOI TEL NO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith 4 ��}�SIVA U FRONT comply with such provisions or this permit shall be deemed revoked AppgEg ��1 ( � P L LICENSED CONTRACTORS DECLARATION SJR ' PILE CITY i(" " LIC _S P L • I hereby affirm that I am licensed underprovisions of Chapter 9 l SEWER MAP (commencing with Section 7000)of Division 3 of the Business and S�F�SIZ NO OF STy4RIES NO OF F MILIES Professions Code,end license Is In full force an ffe LIL I _XS:4 NEW Bk PG a- G� DE P 10 F WORK VALU ON U License Num//be``r,, Llc C� � � °n� 1/ ADD ❑ 0 Contractor X14�� Date JN�1��1I ll LTER ❑ ��' 1 N ElI am exempt under Sec REPAIR ❑ 0 B&PC for this reason `?� lV DEMOL ❑ LDMA P/C# LLI Date USE OF EXISTING BLDGURM ❑ Signature CO A NT TE NO LDMA Perm# Z RpWf�'A��I) C Q, w a ❑ I, as owner of the property, or my employees with wages as �^�`� ^' �V� Z �7CCTA their sole compensation, will do the work and the structure Is A4R,1 O not Intended or offered for sale (Section 7044, Business and �j{�� J'� ) TA A) FINAL DATE Q _307 PfofesslonS Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 6— 9 4 ITEMS El 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 MATERIALS INFORMATION GUIDE1Q licensed contractors to construct the project (Section 7044, FINAL BY >VES El No ElTI_ITAL :117 m 90 Business and Professions Code) r WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDINGOCCUPANT l,�IEl•r� 17 n 9!_I OAST AIR QUQAU TY MANAGEMENE A PERMIT T TRIISCAQMDUCTION R EOEDPERMI ITT NG ON 0 E KUSM THE TOFOR g� - J•. i'I� CONSTRUCTION LENDING AGENCY l yy GUIDELINES �)��]� °L1 I hereby affirm that there is a construction lending agency for YES 1:1No El th a e performance of the work for which this permit is issued(Sec I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,CIV C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, l)LIU��(� y {1 :il/g TITLE 2,CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS -000 1"!77 z Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD Q Lender's Address 9661 1 AM f:51 OWNER OR AGENT o I certify that I have read this application and state under penalty O of perjury that the above Information Is correct I agree to comply PC FEE PERMIT FEE with all county ordinances and State laws relating to building m construction, an y authorize representatives of this County ISSUANCE FEE to enter o roperty for Inspectio os rps -�_.�� INVESTIGATION FEE TOTAL FEE SQ—d Aoa�cem a Ac l i SEE REVERSE FOR EXPLANATORY LANGUAGE APPUCAMON FOR BUILONG PERMIT COUNTY OF'LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION BUILDING ADDRESS ' FOR APPLICANT TO FILL IN BUILDING ADDRESS � ° J� � S O1V � I hereby-affirm that I have a certificate of consent to self Insure, LXVC— pyqy— or a certificate of Workers' Compensation Insurance,or a certified copy,thereof(Sec 1 388,000,Lab C) CITY _ ZIP &1 Pollcy-NA7 ��9 Company u ,C) O LOCg�Tf_ ' SIZE OF OJ„ NO O BLDG NOW ON LOT —`�.• ❑ Certified copy is hereby furnished' �Jl NEAREST CROSST I Njq:ertified copy is filed with the county building Inspection TRACT �� BLOCK LOT NO 45- USE ZONEMSPECI depar�'t—ml/eR(1t/ ! '`Da � ` Irk Applicant_L�] I._�iv CSO r�Y�' ASSESSOR MAP BOOK PAGE PARCL- f 7? �'� �..""t CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNE T L NO _ COMPENSATION INSURANCE �jTAR�ZS NAL Q S�� WITHIN 1000 FT OF SCHOOLS YES No (This section need not be completed if the permit is for one Hundred ADDRESS155N0� dollars ($100)or less) 7 DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY CITY ZIP 1 certify that in the performance of the work for which this permit Z<z5cww�!p 90�� O Q — v 3 is Issued, I shall not employ any person in any manner so as to V become subject to the'Workers'Compensation Laws A HITECT OR ENGINEER TEL'NO • STATISTICAL CLASSIFICATION APT CONDO .,Date- Applicant ADDRESS - - CLASS NO :;2/ 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 -�^�l �'fa� O ��/'� SET BACK YARD HWY PROP LINE WIDTH Compensation provisions,of the Labor Code, you must forthwith (J W lw s iJ �lG��/ K/ FRONT ,comply with such provisions or this permit shall be deemed revoked AD R S LI GNQ� P-L LICENSED CONTRACTORS DECLARATION AV, J 1I SIDE CITY ,� � - `,�p�� _ LIC LASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 1 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ�.9F� NO OF STORIES NO OF FAMILI S Professions Code,and my licennse is m,full'force a effect 1 v NEW BK PG D a License Number LIC CI DESCRIPTION OF WORK ADD ❑ VALUATION O Contractoi 'XTOii`- CC2'j}ISrP DateALTER ❑ $ Op' ❑ I am exempt under Sec REPAIR ❑ $ 0 B&PC for this reason DEMOL'-❑ U LDMA P/C# W Date USE OF E TING BLDG URM ❑ Signature LAPP=NT(PRINT) TEL NO - LDMA Perm# Z ElI,-as owner of the property, or my employees with wages as (� Z P,t T°T their sole compensation, will do the work and the'structure is ADDRESS O �' , I� not intended or offered for sale (Section 7044, Business and FINAL DA Q 63 {sy Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL' El I, as owner of the property, am exclusively contracting with '' i'I• t I-,tT�t i� OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE AMOUNTS SPE IFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY VES[IN licensed contractors to construct the project (Section 7044, TOTAL 103. 05 Business and Professions Code) � _ � •I,'t yy-)� WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING - CHECK OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH COAST CONSTRUCTION LENDING AGENCY GUIDELINES AIRUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKDST FOR CHANGE 1 hereby affirm that there is a construction lending agency for YES❑ No� ll v the performance of the work for which this permit is issued(Sec IHAVEREADTHEHAZAR USMATERIALS INFORMATIO G E AND THE SCAOMD PERMITTING 3097,Civ C) CHECKLIST I UNDERS DMV REQUIREMENTS UN R E LOS ANGELES COUNTY CODE, 11�1'ti �I�(;i'7•1 7/21/9-3 '�i / ; TITLE 2 CHAPTER 2 SECT NS 2 20 100 THR H 20 140 CONCERNING HAZARDOUS .! 00 001 1! 3 Lender's Name MAT POR FO BTAINING A P FROM THE SCAQMD o Lender's Address 0845 1 011:06,, O OKTJER OR AGE o I certify that I_have read this application,and state under penalty _ of perjury thAabovefAg ee t0 comply PCFEE PERMIT FEE N with all coug to building .< construction, f this County ISSUANCE FEEco to.ent tion urposes a INVESTIGATION FEE TOTAL FEE /O.? Q� ^ saner «a Afleni a �J SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION I hereby aftirm that I have a certificate of consent to self D i P��C A U P O M FOR, OR p u d�D�M IGP E R nn�" insure; or•a ct-rtificate;of Workers' Compensation Insurance, L111 lJ /l�1 LI V LI�1 LI LJVIJ�Ju or a certified copy thereof (Sec 3800, Lab C ) ?COUNTY OF LOS ANGELES BUILDING AND SAFETY ` Policy No 12Z-5117 Company STATE i l29 d Q Certified'copy is he furnished FOR APPLICANT TO BUILDING•FILL IN ` ADDRESS" 10!�S v- UVE 0.,W4 AVE Certified,copy is filed with the county building inspec- gDDRING E55 'bSSgj � A tion department- ` Date IZ I � Applicant"T�?�-GO+�GOK CITY U ZI11 O LOCALITY ' C3T NO OF BLD S NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS'' - SIZE OF LOT NOW ON LOT, O . CROSS'S? EL MON'T E COMPENSATION INSURANCE / ASSESSOR (This'section need not be completed if„the permit is for one TRACT- �j- BLOCK• LOT NO 7 e MAP BOOK -85•g�D PAGE 2- PARCE21 ZZ hundred dollars-($100) or less ) TEL USE ZONE MAP OWNER x.12-CS "-r ✓ NO - NO SON L� I-certify that in the performance,of the work for which this 5a P permit is issued, ],shall not employ any person in,any manner ADDRESS L6U� 4. r I SPECIALCONDITIONS a so as to become subject to the.Workers' Compensation Laws O _ CITY . 4:VS ZIP 2? r U :Date Applicant ARCHITECT OR TE� � ENGINEER J DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT If_after making,this Certificate of �O NO �`I �� CONST J Z E o Exemption, you,,should become subject to the Workers' �A /n� �( V Compensation provisions of the Labor Code, you must forth- ADDRESS[% 11'' �N r J w li CL with .comply with such provisions or this permit shall be ` NO STATISTICAL CLASSWICATION APT CONDO Z' deemed revokedCONTRACTOR K LICENSED CONTRACTORS DECLARATION LIC CLASS NO O D DWELL UNITS' , F I.hereby affirm that I am licensed under provisions of Ch6pter•9 ADDRESS 'OBJ s•5�� .� NO:�✓ ' T , (commencing with Section 7000)of Division 3 of The Business LIC SEWER MAP `� and Professions Code,and my license is in full force and effect CITY Y►1 CLASS BK �8 '� VAI DATION .••�Q SQ_FT' ' NO OF NO'OF CHECK - !•�•r .� License Number Sl1 /d ' Lic. Class SFAMILIES ONE VALUATION - 3307 1533,37; Contractor I =1�`"M �Mv l Date �Z DESCRIPTION OF WORK S•F.0 rV41.0 Z4 NEW i }� r _ ADD Ele - - 1 JTEMS ❑I am exempt under Sec u D c-,•; _ ALTER ❑ a��f :•oao.� T�.tTRi� 1•.��5.:: B 8P C for this reason REPAIR ❑ $ CHECK Date USE OF t:nG�•f, ick 1.i ci EXISTING BLDG N DEMOL ❑ C_HHHGE ; .01ISignature APPLICANT TEL FINAL 1 d f I (PRINT)' S T] � NO CZ OWNER-BUILDER DECLARATION DATE 73 I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business'and - ADDRESS - FINAL *�-01131 i21r 14f Professions Code)' PRESENT 'a BUILDING - B Y t. - ❑ I, as owner of the property, or my employees with' ADDRESS r ,S,�gTro wages as their sole compensation,will do the work and /�`" < ' the structure is not intended or offered for sale(Section 44LOCALITY O ' r fj�'��1 70 , Business and Professions Code ) MOVING TEL _ i' •� rrT 8 CONTRACTOR Iti NO 1 3 11,V !� r/ ACC"T.e 8 ❑ I, as owner of the property, am exclusively contracting L '< < I/ •/I' 1 _ with licensed contractors to construct the project Sec- "4 'Y` f 4 ✓'� �`; r',c ;+ t/t _/��` `t ^y' - I_ 19 t P I ( a ADDRESS � � -. i ., ..,}i.1�7 ,1 vaiL tion 7044, Business and Professions Code ) REQUIRED TOTAL SETBACK FROM' EXIST ~' ,a;. .ITEMS ' CONSTRUCTIOWLENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH "� I hereby affirm that There is a construction lending agency for FRONT, t.@S� .t_ 1 ` •" TOTAL the performance of the-work for which this permit is issued P L - .• , CHECK (Sec 3097, Civ, C ) SIDE° i t c, r� ; L'ender's Name J. `t V`,i:HA� Int] ; 3) LDMA Ref # '� o P C Fee $ Permit Fee Lender's Address I certify that I have read this applicatiori and state that the �� Issuance Fee /" LDMA P/C q' ® Ijul-OCi01 3/11/9, 8 above information is correct I agree to comply with all County Investigation Fee' /�� n; / {;{� ordinanc/anState law relating wilding construction, Total Fee 1f to LDMA PeFm "q t.K3 -1 AMID-41and on a re esentati s o This County to enter up them ti a rop ty r inspection ur oses - SEE REVERSE FOR EXPLANATORY LANGUAGE Signa ure of Applicant ge Dat _