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HomeMy Public PortalAbout9216 LIVE OAK AVE_Building__ WORKERS' COMPENSATION DECLARATION herby.of certificate that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT 'insure, or a certificate of Workers' Compensation Insurance, ' &,a certified copy thereof (Sec. 3800, Lab:C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING q2� LAVE OAK tion department. ADDRESS ! / Q CITY LR, Vf, zip 1 Igo LOCALITY ' Date Applicant O. OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT SODS X OW ON LOT ' NEAREST CROSS ST. COMPENSATION INSURANCE Q ASSESSOR SS� (This section need not be completed if the permit is for one TRACT � ' BLOCK LOT NO: (J MAP BOOK PAGE 00 PARCEL hundred dollars ($100) or less.) TEL. OWNER " i ZJI, NO. �/ USE ZONE MAP 7 //_ /i � / NO. 7 _ oci 4o I certify that in the performance of the work for which this y�' - I permit is issued, I shall not employ any person in any manner ADDRESS /�� V4y� ZDSPECIAL &� CONDITIONS O so as to become subject to the Workers' Compensation Laws. �1 �r p 2 CITY /k�la�«cb1'rr�. ZIP C l0 v J U Date Applicant ARCHITECT OR TEL. 0 NOTICE TO APPLICANT: If,.after making.this Certificate of ENGINEER /�Q(� NO. DISTRICT GROUP TYPE FIREkR(CESSED BY CONST. ZONE O Exemption, you should become subject to the Workers' w Compensation provisions of the Labor Code, you must forth- ADDRESS ��s[.srG's is with comply with such provisions or this.permit shall be TEL- STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR Lam% /�� NO. — LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. � DWELL. UNITS — LICENSED hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO' SEWER MAP LIC. (commencing with Section 7000)of Division 3 of the Business VALIDATION and Professions Code,and my license is in full force and effect. CITY CLASS BK. /— PG. - _ SQ. FT. ✓ NO. OF NO. OF CHECK License Number Lic. Class SIZE 37,02 STORIES FAMILIES_ ONE- VALUATION _ Contractor- Date DESCRIPTION OF WORK NES/`/ ❑ $ El am exempt under Sec. X151 15 GAR CzARA&F C0AJVEkfADD ❑ ► ALTER B.&P.C. for this reason TO UsE 5 D/ GTb R44n�i REPAIR ❑ $ Date: USE OF DEMOL r_1EXISTING BLDG. Signature APPLIC NT NO. FINAL n OWNER-BUILDER DECLARATION DATE �g 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINALS _W Professions Code): PRESENT By I' - ❑ I, as owner of the property, to with BUILDING P P Y+ or m Y em P Yees ADDRESS wages as their sole compensation,will do the work and , _ the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. CONTRACTOR NO. I, as owner of the property, am exclusively contracting ,: .•.- - with licensed contractors-to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) tr' REQUIRED TOTAL SETBACK FROM EXIST. -- -•- CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH r;w I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued 'P.L. �x _.zJ_.; (Sec. 3097, Civ. C.). SIDE. i i.6 y __ 5s P.L. Lender's Name. 7.$ � Ofd LDMA Ref. # P. Fee$ -15,10Permit Fee , ; 1L. 3 Lender's Address r 0 1' certify that I have read this application and state that the Issuance Fee 7J LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee %__), 8 Q • LDMA Perm. # R ordinances and State laws relating to building construction, Total Fee • and herebyaut re resentatives of this Count to enter ""°?L i- 'i m P Y L.�r•i i tis:I.::_ r: upon the a mentio �o erty for inspectio purpo es. I . SEE REVERSE FOR EXPLANATORY LANGUAGE Signature ofplicant or Agent Date WQR�r.ERS' COMPENSATION DECLARATION • hereby certificate consent self nertifcate'of Workers' Insurance, APPLICATION Fb R BUILDING- PERMIT or 6 certifiedccopy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Pblicy No. •- Company BUILDING i Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS zi Date Applicant CITY d ZIP LOCALITY r NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT O. NOW ON LOT L CROSS ST. COMPENSATION INSURANCE ASSESSOR p / pI �,� (This section need not be completed if The permit is for one TRACT BLOCK LOT NO. MAP BOOK---y,37�Q PAGE v0/ f'ARCEL �0 hundred dollars ($100) or less.) TEL. O OWNER U � NO. USE ZONE P I certify that in the performance of the work for which this �0 / permit is issued, I shall not employ any person in any manner ADDRESS / CONDITIONS a so as to become subject to the Workers' Compensation Laws. O CITY ZIP U Date Applicant ARCHITECT OR f / TEL. NOTICE TO APPLICANT: If, after,makingthis Certificate of ENGINEER f1/�/ NO. DISTRICT GROUP TYPE FIRE PROCESSED BY CONST. ZONE U Exemption, you should become subject to the Workers' ee f U Compensation provisions of the Labor Code, you must forth- ADDRESS "6�J O M 7 with comply with such provisions or this permit shall be `TEL. STATISTICAL CLASSIFICATIONAPT. CONDO. to deemed revoked. CONTRACTOR NO. .� Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. e4- UNITS _ _ hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. _ - LIC. SEWER MAP (commencing with Section 7000)of Division 3 of the Business - '•"' _y .and Professions Code,and my license is in full force and effect. CITY CLASS� BK.Zi PG. �� 'VALIDATION SQ. FT. _ NO. OF NO. OF CHECK License Number Lic. Class 1i\ SIZE STORIES _ FAMILIES ONE V,J VALUATION � Contractor Date DESCRIPTION OF WORK NEW ❑ ; q DO V�.�J i o/V ° ?Xi �>1L ADD v ► ;7•:s, .._. ❑I am exempt under Sec. Q "T`- �ia�:'•r ALTER ❑ •t" .�,i,,". •;i,,i B.&P.C. for this reason ��� 1:� G?r' LS USE OF G � '�a� 7L LG REPAIR ❑ - Date:' EXISTING BLD �d_-C DEMOL 0 - Si nature APPLICANT 'MC6kT TEL �' ' • t 7f'j }; {1 t `r g OWNER-BUILDER DECLARATION (PRINT) ) I NO DA EL��ZS �f( ,q, t F I hereby affirm that I am exempt from the Contractor's Licensepts, �3V -' - - - Law for the following reason (Section 7031.5, Business and ADDRESS /7�7 FINAL Professions Code): '1` PRESENT By vu ;;-,•I; t,'t ❑ I, as owner of the property, or my employees with BUILDINGADDRESS ­7 wages as their sole compensation,will do the work and r; LOCALITY the structure is not intended or offered for sale(Section loop, t• � '-•��i'`"== �_- 7044, Business and Professions Code.) MOVING TEL. - I, as owner of the property, am exclusively contracting CONTRACTOR NO. - with licensed contractors to construct the project Sec- I._a P I ( ADDRESS t i•i,__.! .1t ��: -_ tion 7044, Business and Professions Code.) _ REQUIRED TOTAL SETBACK FROM EXIST. e - CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L.. Lender's Name LDMA Ref. # P.C. Fee$ t�C 4•Dit- Permit Fee , � Lender's Address o I certify that I have read this application and state that the Issuance Fee a/' 75 LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee Q Sordinances and State laws relating to building construction, Total Fee �� O LDMA Perm. # a and hereb ze representatives of this County to enter upon�ve�--- property for inspection pu oses. a inspection ,` SEE REVERSE FOR EXPLANATORY LANGUAGE L-Signatur f Applicant or Agent Date / 1 APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING DDRESS BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, — 2 j L vt QA or a certificate of Workers' Compensation Insurance,or a certified copy thereof.(Sec.3800,Lab. C.) CITY 'rgNIPtF- �� ZIP 7 G LOCALITY Policy No: Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. El Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. Date Applicant ASSESSO M OOK PAGE PARCEL �' ®Q d L SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER t!{ TEL NO. YES NO COMPENSATION INSURANCE J ��G�� WITHIN 1000 FT.OF SCHOOL? (This section need not be completed if the permit is for one hundred ADDRESS 09K DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) ZIP I certify that in the performance of the work for which this permit CITY is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. ARCHITECT ORR ENGINEER TEL NO. STATISTICAL OSSIFICATION APT CONDO Date Applicant ADDRESS CLASS N0. �._� 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 TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwithFRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P IL SIDE LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS 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 SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW 1:1 BK PG , d ADD ❑ VALUATION License Number Lic.Class DESCRIPTION OF WORK 4crU � Contractor Date �/ �� f ALTER $ l." RpfVl©1 - 7-- -X I y�! REPAIR ElO $ ❑ I am cc exempt under Sec. B.BP.C. for this reason 5ftlNlV\. DEMOL ❑ LDMA P/C# III Date; USE OF EXISTING BLDG. URM ❑ 0_ f C0 Signature APPLICANT(PRINT) TEL NO. LDMA Perm# — z ❑ 1, as owner of the property, or my employees with wages as ZO —Ai •t_•: �'a: 6. their sole compensation, will do the work and the structure is ADDRESS FINAL DATE not intended or offered for sale (Section 7044, Business and el+ ~! '.,;jl ' - -- Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A K41XTURE CON5 El 1, as owner of the property, am exclusively contracting with AMOUNTS S EC FIIEDTAINING ON HE HAZARDOUS MATER AA HAZARDOUSILS INFFORMATEQUALTIIONRGU DEE? THAN THE Q I i FINAL BY > licensed contractors to construct the project (Section 7044, YES El NO❑ �� I I 87 - 55 Business and Professions Code.) € __ =� WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT f OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH C E •{;' —� G-- CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR f�Hh� GUIDELINES. C •'' 1,3t f'P I hereby affirm that there is a construction lending agency for YES❑ No❑ a the 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, N TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUSI—S I1''40S �.;.Ii.. JtJ.L f.•`i i r .`J Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. o Lender's Address 0906 s °u 1 OWNER OR AGENT AM O 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 P.C.FEE PERMIT FEE o with all county ordinanc and State laws relating to building con structi and "ya rize representatives of this County ISSUANCE FEECO " to en uped property for inspection purp, es. Z INVESTIGATION FEE TOTAL FEE S nature nl nt Dai SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDIN �ES I hereby affirm that I have a certificate of consent to self insure, BUILDINa ADI S or a certificate of Workers' Compensation Insurance,or a certified t_i U r— OA copy thereof (Sec.3800,Lab.C.) ZIP CITY „ �t G �,� LOCALITY Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE Z NE MAP NO.' Date Applicant. ASSESSOR MAP BOOK PAGE PARCEL ��If �/ �}� SPECIAL CONDITIONS � CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER 14v, ZHe.1/. TEL NO. YES NO COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? (This section need not be completed if the permit is for one hundred ADDRESS ,1 �! A y f'�l� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100)or less.) CITYZIP I certify that in the performance of the work for which this permit 7 AliL u T is issued, I shall not employ any person in any manner s0 as to ARCHITECT OR ENGINEER TEL NO. become subject to the Workers'Compensation Laws. 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' CONTRACTOR TEL 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. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION PILE CITY LIC.CLASS 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 SQ.FT.SIZE NO.OF STORIES NO,OF FAMILIES Professions Code,and my license is in full force and effect. 360 NEW BK /-- PG Q DESCRIPTIO OF ORK ADD E] VALUATION License Number Lic.Class - *2_ O� Contractor Date ALTER ❑ I am exempt under Sea O REPAIR- 1:10 BAP.C.for this reason DEMOL ❑ LDMA PIC# ` W Date: USE OF EXISTING'OEDG. URM ❑ 0- Signature APPLICANT(PRINT) TEL NO. LDMA Perm# _ •" - z El I, as owner of the property, or my employees with wages as z rt!•� .a their sole compensation, will do the work and the structure is ADDRESS _. c not intended or offered for sale (Section 7044, Business and FINAL DATE �� n Q 330 •0.511 Professions Code.) Z "GT WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE AHAZARDOUS MATERIAL� J I, as owner of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Y 9 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? L, FINALEBY/I , 'T y licensed contractors to construct the project (Section 7044, YES El NO 1:1 ACCT.ACs s .T Business and Professions Code.) WILL THE INTENDED USE OF THE SUIDLING BY THE APPLICANT OR FUTURE BUILDING - 113 I C} it Hyl I OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ''•ri` � CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR - ' GUIDELINES. EM I hereby affirm that there is a construction lending agency for YES❑ NO❑ �h m the performance of the work for which this permit is issued(Sec. TOTAL 535 o 10 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, {{ N TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS CHECK 535.10 3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. o Lender's Addresst•HF NUt .13 I O OWNER OR AGENT 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 P.C.FEE PERMIT FEE o n �/ a with all county ordinances and State laws relating to building �!f"•�® / yl—�I�ILIi It •,Z }L� ro CORS CtiOn, and hereby authorize representatives of this County ISSUANCE FEE •'ti �1 i ci �•. enter upon I ve mentioned property for inspection p4SS T,i11 HI i =_ �r�a �ZINVESTIGATION FEE TOTAL FEE ', / D S'nature of A n[ r Daie (p SEE REVERSE FOR EXPLANATORY LANGUAGE