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Home My Public Portal About10562 LIVE OAK AVE_Building__ APPUCAMON FOR BULUNGPERN'T COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION ,: , FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have'a certrficate of consent to self insure, BU L IN DD SS y" or a certificate of Workers' Compensation Insurance,or a certified -copy thereof(Sec 3800, Lab C) CITY , lJ0� A ZIP (�' f -I LOCALIT Policy NO-. Company SIZE OF,q4 :NO OF BLDGS N ON LOT ' • ❑ Certified copy Is hereby furnished ri I NEAREST CROSS ST rip BLOCK LOT NO n ❑ Certified copy Isyfded with the county building,inspection T on - 111 , USE ZONE , MAP NO department �, _ � - - • ' . -. • Date Applicant ASSESSOR MAP BOK PAGE PARCEL pp - SPECIAL CONDITIONS - CERTIFICATE OF EXEMPTION-FROM WORKERS' wNF�j�S L / hNO �1 t�SLJ COMPENSATION INSURANCE pn11g��11 _I ✓ WITHIN 1000 FT OF SCHOOLS YES NO (This section need not be completed If the permd Is for one hundred ADM C* DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars ($100) or less) V�VV��vV l V CITY ZIP I certify that in the performance of,the work for which this perfni q, O Is Issued, I shall not'employ any person'in any manner SO'aS to E T R ENGIN ER ,,{;'1 TE NO !/ beCO•I'tl �subthe Workers'COri1 �S,a(Ilon Laws �� CLATSS NOL CLASSIFICATI SELL UNITS P� ODatApphCanf"7LN 'IV �'I VI 1 ADD�j E S NOTCEICANT If, after making this Certificate Of -I1 �� `� ' ' REQUIRED TOTAL SETBACK FROM EXIST ExemptlOn, you Should become Subject t0 the Workers' C NTRA TOR N�, SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith CJ-j10 dU FRONT comply with such provisions or this permit shall be deemed revoked AD S A t LC P L V- SIDE - - LICENSED CONTRACTORS DECLARATION ^ CITY LILiSS P L c I hereby affirm that I am licensed underprovisiohs of Chapter 9- SEWER MAP (commencing with Section 7000)of Division 3'of the Business,and• �.S)Z NO OFfTOR ES NO OF F.!•MILIES NEW BIC PG >' Professions Code' d y license Is In full force�Rd eff ct UU �,� D •I ` D SCRIPT N OF WORK ADD ❑ VALUATION Q License Nu ber, Llc Class Contractor Date &41 ALTER ❑ $ •❑ I am exempt under Sec, ' REPAIR 1:1 $ 0 B&PC for this reason V L� �/ DEMOL ❑ V LDMA P/C# W Date USE OF EXISTING BLDGURM ❑ - C- Signature' A P R/NT - T N�y�1r LDMA Perm# � Z ❑ I, as owner of the property, or,my employees with wages as V ' z ACCT their sole compensation,,will do the work and the'structure Is AD / not Intended o'r offered for sale (Section 7044, Business and L~ �l� FINAL DATE a ,�'I�f{{ Professions Code) " WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 1 ,ITEI l ❑ I, as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY ' - licensed contractors to' construct the project (Section 7044, TOTAL 1 :,7 m 90 VES❑ NO❑ Business and Professions Code) WILL THE INTENDED USE,OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING (,(-(E ,�� 10.9"i� OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _ CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR (�qI'j' I hereby affirm -that there Is a construction lending agency for- GUIDEYES El No ElLINES - '44 ' - E a 0113 �- CHANGE'1U the performance of the work for which this permit Is Issued(Sec IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE ANDTHESCAQMDPERMRTING 671 N 3097,CIV C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, ��( �{ (�(�/ f iry- TITLE 2 CHAPTER'2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS i-7i1 '[.t—VLiL� •1f la.i 7: Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD o Lender's Address9665 O OWNER OR(GENT oI 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 �y , o with all county ordinances and State laws relating to building p� In m construction, and hereby a onze representatives of this County ISSUANCE FEE to enter upo d roper for Inspects pur ses7,1 a �J��/� � INVESTIGATION FEE TOTAL FEE Q r e o q�nt a nt aze 7, SEE REVERSE FOR EXPLANATORY LANGUAGE r ; ; apL° UC AMON FOR BUJLDONG PERMT , �. COUNTY OF LOS ANGELES BUILDING'AND SAFETY FOR APPLICANT TO FILL IN BUILDING ADDRESS V t5 WORKER'S COMPENSATION DECLARATION ' 1 hereby affirm that I have a certificate of consent'to self Insure, BUILDING ADDRESS or,a certificate of Workers' Compensation Insurance,or a certified copy,thereof (Sec 3800,Lab C) CITYTE� "Cl Policy,No IZZ�J�7 CQmpany`510<f� �'.f V!o 1LC- G1� •� V LOCALITY vl,•,C , SIZE OF LOT' NO OF BLDGS NO ON LOT r P Elhe Certified copy is hereby furnisd -11 NEAREST CROSS S Certified copy is filed with the county budding Inspection , TRACT r BLOCK LOT NO GiG- a depart e •• "JUSE ZONE MAP NO ` A Ilcant l T .�'N 5� ASSESSOR MAP BOOK PAGE i PARCE ^' • `� `_ ' Date pp t/U_ t ^�_ SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS'- OWNER— COMPENSATION TE NO 1 COMPENSATION INSURANCE' S � YV 4S5-75' WITHIN 1000 FT OF SCHOOLS YES NO (This section need not be'completed If the permit Is for one hundred ADDR SS ' _ �•�ljs�-.� DISTRICT GROUP TYPE CONST FIREtZONE PROCESSED BY dollars ($100) or less).less). _ CITY ZIP f I certify.,that'in the performance of the work for which this permit 1, •'d$' �- 3 is Issued, I shall not employ any person in any manner so as to ,become subject to the Workers'Compensation Laws ARCHITECT OR ENGINEER TEL NO P 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- t0 the Workers'' CONTRACTORµ^" �iv, t� .. NO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of,the Labor Code, you must forthwith �l�G�-•7 N7 FRONT comply with such provisions or this permit shall be deemed revoked A RESLIC S P L SIDE LICENSED,CONTRACTORS DECLARATION CI Y" I CLASS P L I hereby affirm that I am Ilicensed underprovlsions of Chapter,9 SEWER MAP (commencing,with Section 7000),of Division 3 of the Busmess•and S�&L$IZE NO OF STORIES NO OF'FAMIL S NEW 11 BK PG Professions Code,and my license Is'in full force an effect `�� D D_ License''Number�� U� ,PLIC CIasS DESCRIPTION OF WORK �� ADD ' ❑ VALUATION' Q Coritractor' = �aN {Date _ ALTER ❑ $ U ❑'I am exempt under Sec < REPAIR El $ t3 B&PC for this reason DEMOL ❑ LDMA P/C# < W Date USE OF EXISTING BLDG URM ❑ Signature _ AP LI ANT,(PR/NT - TEL.NO , LDMA Perm#- " .. +'y �' - Z ❑ I, as"owner of the property, or my employees with wages as thelr'sole Compensation, will do the work and the structure Is ADDRESS 33017 � { not Intended or offered for'sale (Section 7044, Business and - FINAL DATE - "Q ,.+�+0iy, 3�1}j a!I•. PfOfeSSIORS Code) , WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 'I ❑ I, as owner.of the property, am exclusively contracting 'with OR A MIXTURE CONTAINING A'HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q r I ITEMS AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE'SL - Ilcensdd contractors to construct the project (Section 704'4, VES 1-1No� -- FINAL BY. > M 3TAt1` :103 ® 05 Business and Professions Code) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING - r•il�l•!: [[,,�� ^(,' •� 3 i � OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKUST FOR CONSTRUCTION LENDING AGENCY GUIDELINES -r the performance of the work for which this permit Is Issued(Sec CHANGE I hereby affirm that there is a construction lending agency for" YES❑ o a (HAVE READ 7HE HAZA SMATERIA INFORMATIO UI AND THE SCAQMD PERMITTING a ' 3097, CIV C) CHECKLIS DE MV Q EMENTS UND T LOS ANGELES,COUNTY CODE, '� _ { _ ' TITLE PTE SECTI 0 100 THROU 2 0 140 CONCERNING HAZARDOUS hV —I�(�Q 1 +, !.r�j 1!O Lender's Name MAT S REP N N GAPE IT ROM THE SCAQMD 1 f 7 CL Lender's Address f AN i I:Cly. O - OWNER OR AGE , o I certify that I have read this application a state under penalty of perjury that the e Information Is c me t I agree to,comply PC FEE j PERMIT FEE (D- �� e with all county di a es and State aw relating to building oo construction, re or, rep s tativeS Of this County ISSUANCE FEE V) to r upo abo n d pro y for inspection purposes a a - INVESTIGATION FEE TOTAL FEE /D of rowel o,Agent IDWe J SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION • insure,by or a ccertif cate of Workers' t' Compensaon consent Insurance, Q LO or a certified copy thereof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY . -Policy Nol=Z• . %b �'• CompanyBUILDING �11,i�!J ❑ Certified copy is hereby'furrttshed. 4; FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county-building inspec- BUILDING- ' LI VG tion de artment. ADDRESS 1;7,4p4o Z- uG C71AK �"� IX Date ?' -`Z Applco 71 zo,NyT CITY ZIP LOCALITY NO OF BLDGS NEAREST Co CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST -COMPENSATION INSURANCE ASSESSORt� (This section need not be completed'if the permit is'for one TRACT' Z BLOCK LOT NO I MAP BOOK '615F, PAGE L PARC 'Z hundred dollars ($100) or less') tt �1f, ' TEL USE ZONE. OP 1 OWNER T S 1 V.4L- QF N (o ��J 57ov4 I certify that in the performance-of the work for.which this ,� {� D I SPECIAL'` permit is issued, I shall not employ any person in any manner ADDRESS -5 1(�U1� A 'r+.5_0 r_` CONDITIONS a • so as to become subject to the Workers' Compensation Laws ' ^ 11 Q CITY l�F I�IVG ZIP {.. (U Date 'Applicant ARCHITECT OR TEL DISTRICT GROUP TYPE: FIRE PROCESSED BY NOTICE TO APPLICANT• If, after;making]-this Certificate of ENGINES NO, O CONST ZONE Exemption, you should become subject- to the Workers' A' ` u 5'•d$ Q-� v 2 ADDRESS /M'�✓ J W Compensation provisions of the Labor Code, you must forth- i1 with comply with such provisions or this permit shall 'be -r' TEL g STATISTICAL CLASSIFICATION APT CONDO Z deemed revoked ' CONTRALTO (�," l� 7 NOg p Z D oQ' y _Z LICENSED CONTRACTORS,DECLARATION LIC CLASS NO DWELL ,UNITSE _ • I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS <C35154,111'J&.74 NO 45 O ' SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC C i z ,and Professions Code,and my license is in full force and effect CIN ��'�'� G NU" CLA55 gK pG `' VAIILTDATION 'f Q SQ FT NO OF NO OF CHECK License Number 5 1 ,O Lc Class SIZE 2STORIES FAMILIES ONE (� VALUATION' IS ContractorN �� 1 Date �Z DESCRIPTION OF WORK FQ NEW S � Z E' li ❑I am exempt under Sec ADD ❑ TOTAL s.5L4«_ ALTER. ❑ deD• D t'H B&P C for this reason REPAIR ❑ $ �1�t' °i- ` Date _ EXISTUSE NGBLDG DEMOL,❑• C'HANGE APPLICANT _ TEL • - � -"' Signature -(PRINT}S ?S t NO FINAL OWNER-BUILDER DECLARATION DATE - I hereby affirm that I am exempt from the Contractor's License // ,^, � 7 •�ii.)i3-01001' 1Lr•!,,t Law for the following reosori (Section 7031 5, Busi'ness'and ADDRESS�L.w 5 �� FINAL:' Y-• cZ Professions Code) - _ PRESENT - -.. .. .By ❑ I, as•owner of the ro ert or m -employees with BUILDING y P P Y, YADDRESS �p ti`s � tr{HC•C•i°4 " wages as their sole compensation,will do the work and 9 P n: C t' -�-� c the structure is not intended or offered for sale(Section n D �V°3307 102'.5:-- 4, 70Business and Professions Code ) MOVING TEL . ; ', �! 1■,� ❑ I, as owner of the property, am exclusively contracting NO g V_ AA1ff��tl/�� . with licensed contractors to construct the project (Sec- ADDRESS * M. t t744T 8 tion 7044, Business and Professions Code ) "^ •__ ^ °g REQUIRED TOTAUSETBACK'FROM EXIST . ~t• Lf,., '+ 0 i - CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH, !' 6307 .?C)1 .�L , 1 hereby affirm that there is a construction lending agency for FRONT �,, the performance of the work--for which this permit is issued P L � �' ITEMS (Sec 3097, Crv'C ) SIDE "�� t�-� �j}1��t`{ p ,P L -. — �.;'� .. ,n_ _ ��'+:t r'LLI i 117.='7 Lender's Name L IDMA Ref # ,, ' .lam^t 1 C tl�C! `111G ^^ P C Fee$ 2:6Permit Fee �✓ v Lender's Address E C.HM� I certify that I have read this application and state that The Oo?' Issuance Fee �� ' LDMA P/C# 4 above information is correct I agree to comply with all County Investigation Fee ordinances and State jaws relatin to b in construction, Total Fee . LDMA Perm # t-}� �f��{�� 9 9 � � �O` � LII��'tr.+SJU 1 3/11/97 a and a aut oriz representatives t s County to enter up abov m do ed property or spec on purposes _ E cr 4 ( 11�4c SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date