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HomeMy Public PortalAbout5742 LOMA AVE_Building__ t ' WORKERS' COMPENSATION DECLARATION " i here y affirm that have a certificate of consent'to. self -APPLICATION "■ 'O Iz BUILDING P E RM I T insure, r a certificate'of Workers'.Compensation Insurance; or a cer ified copy thereof (Sec: 3800, Lab. C.) COUNTY OF.LOS ANGELES BUILDING AND SAFETY Policy-N Company. El - BUILDING v ? Ce ified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Cert ied copy"isfiled with the county building inspec- BUILDING �1 - p tion apartment. ADDRESS- S ac / L ►n'! vii Date Applicant p CITY � CI ! ZIP LOCALITY NO. OF BLDGS. NEAREST ) CE.RTIF ATE OF EXEMPTION FROM-WORKERS' SIZE OF LOT NOW'ON LOT CROSS ST. S'• hGc Tw�a-s OMPENSATION INSURANCE ASSESSOR , (This section ne not be completed if the-permit is for one TRACT BLOCK. LOT NO. MAP BOOK PAGE PARCEL hundred dollars 100) or less.) TEL• OWNER NO. USE ZONE MAP I certify that in th performance,of.the work for which this NO. permit is issued,,I sh IPnot employ any person in any manner ADDRESS, 2 -yn ,// 1"\ SPECIAL" - C fff CONDITIONS so as to become sub ct to the Workers:Compensation..Laws. f O CITY ZIP U Date A plicant -ARCHITECT OR TEL. ENGINEER NO. DISTRICT GROUP TYPE FIRE PR CESSED'BY NOTICE TO APPLICANT. If; after"making this"Certificate of CONST. ZONE � Exemption, you shout become subject to .the Workers- w Compensation provisions f the Labor-Code, you must forth= ADDRESS' with comply with such" aIvisions or this permit shall be TEL. STATISTICAL CLASSIFICATION T. CONDO. to deemed revoked. CONTRACTOR NO. z , LICENSED CONTR CTORS DECLARATION LIC. CLASS NO. DWELL. UNITS ' I hereby'affirm that l am licen d under provisions of Chapter 9 ADDRESS NO. LIC. SEWER MAP -• (commencing with Section:7 )'of Division 3 of.the Business CITY. CLASS ry and Professions Code,and my Ii ense is.in full force and effect. BK. PG. VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lit.-Class SIZE STORIES FAMILIES ONE VALUATION Contiactor Date DESCRIPTION OF WORK �` Ovv% 41 EW ❑ .r . /� �., ' f •. ADD � ✓ ��. I am exempt under Sec: b ".ALTER B.BP.C. for this reason A $ ' REPAIR ❑_ Dat USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT FINAL' J� OWNER-BUILDER DECLARATION (PRINT) NO. / /Q DATE I hereby affirm-that I am exempt from the Contractors License Law for the following reason (Section.703T 5; Business`and ADDRESS . FINA Professions Code):- PRESENT By �N BUILDING - ® I, as owner,of the property, or my employees with ADDRESS re ;$ wages as their sole compensation,will do the work an'd the structure is not intended or,offered for sale(Section LOCALITY ® _r I;' r __t 7044, Business and Professions Code ) MOVING TEL. .t t - CONTRACTOR NO. L t ❑ I,-as owner of.the property, am exclusively contracting _ with licensed contractors to construct.the project"(Sec L $�I{ tion7044, Business and Professions Code.) ADDRESS REQUIRED— TOTAL SETBACK FROM EXIST`* ` " k1i itiL-f i o o+.{E CONSTRUC ON LENDINGAGENCY YARD HWY SET BACK PROP. LINE - WIDTH I hereby affirm that there, :a construction lending agency.for FRONT' lm-Wa.l ( { the performance of the w rk for which this'permit.is.issued P:L.' (Seca 3097; Civ. C.).... SIDE P:t 'Lender's Name E_{ t t;_{ { - m Lender's Address PC. Fee100 17$. Permit Fee'" ��(� LDMA Ref. # �T ' j 1 A E '.0 I certify thcit I have read this plication and state That the Issuance Fee � c LDMA P/C# above information is correct.)ag e`to amply with all.County Investigation Fee' 6 ordinances and State laws relatin o building construction, Total Fee 670 LDMA Perm. # and hereby authorize representatives of this County to enter upo abov -m do erozerty for'inspection purposes. ^• SEE.-REVERSE FOR EXPLANATORY LANGUAGE Signature ppl' n or Agent Date., I l6S-3:25M.SETS 0-45 Y EPAFI'I'MENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT COUNTY OF LOS ANGELES BUILD � �. 1 WM..J. FOX, CHIEF ENGINEER FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY ✓� / /� �A ^ `/ DISTRICT NO. PLAN CK. NO. PERMIT NO. BUILDADDRESNG S /�.{ S t L (/M 4 A V � r- LOCALITYG I l Y -RECEIVED BY DATE OF APPL. DATE ISSUED NEAREST / /JL�. CROSS ST. /y/'T' / U��/1p'T�"J OWNER A r I V�/T � INC, N ADDRESS MAIL 1 N p�� LOCALITY ADDRESS , q .Q� �/Fr/QIV Y/,�J CITY L. S u���"a/ NO. NEAREST TELCROSS ST. FIRE I NO.OF I TYPE it GROUP / ARCHITECT OR TEL. ZONE � PLANS'�'®"'- ENGINEER NO. \ BLDG., ORD. NO. ADDRESS SETBACK LINE l APPROVED , TEL. CONTRACTOR NO. BY DATE USE APPROVED ADDRESS ZONE / BY DATE LEGAL CORRECTIONS DESCRIPTION I LOT NO.,,�3 � BLOCrK TRACT 12 7 7 II 1NO / SIZE OF LOTJ � .k�7 jj I NOWOON LOTS iP� 0V USE OF I NO.OF,I-_NO. OF EX ISTING BLDG. '� FAMILIES ROOMS DESCRIPTION OF WORK NEW ALTERATION ADDITION O A REPAIR MOVING DEMOLISH O SIZEFT �,� ROOMS No-OF STORIES D r WALL ROOF COVERING�,., C ',, / I COVERINGUSE OF t+',f` J BUILDINGG�C_��L✓ APPROVALS I HEREBY ACKNOWLEDGE THAT I HAVE-READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION, NSPECTOR DATE,}, AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS, MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION. FRAME: FIRE STOPS, .SIGNATURE OF BRACING, BOLTS OWNER �:oa��i_ �f�o�' ;LATH, INT.:. L AUTHORIZED AGT`- / ��'�` - .-L'ATH, EXT.: CE P. t $ P. C. S PLASTER, INT. FEE PLASTER, EXT. . VALUATION ..3`�'S�tJ �- FEE , Z 0 6 FINAL DBS-3 AR—T UF:PA'"t►� TSMENT OF BUILDING AND SAFETY I APPLICATION FOR PERMIT COUNTY OF LOS ANGELES S ' ® � 1 WM. J. FOX, CHIEF ENGINEER NG FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY,: BUILDING DISTRICT NO. PLAN CK. NO. PERMIT NO. ADDRESS / 'CAY."t"."e�✓� /��/ �� LOCALITY //// RECEIVED BY DATE AL. DATE/ ISSfUED // NEAREST CROSS ST. � OWNER ADDRESS C � MAIL '`-----. � LOCALITY ADDRESS NEAREST TEL.' CROSS ST. CITY NO. FIRE i NO.OF TYPE__yf/_! GROUP ARCHITECT OR TEL. ' ' ZONE I PLANS I t/ I ENGINEER -NO. V \ BLDG. ORD. NO. ADDRESS SETBACK LINE - APPROVED TEL. BY DATE CONTRACTOR � NO. � \ USE /� APPROVED ADDRESS > ZONE /BY DATE LEGAL DESCRIPTION LOT I LO-TT N/Oq/�{/�/,/',��, I BLOCK CORRECTIONS . TRACT /: -- / / //I j'.J /A NO. OF BLDGS, o� SIZE OF LOT / I NOW ON LOT USE OF NO.OF _ NO. OF EXISTING BLDG. I FAMILIES I ROOMS DESCRIPTION OF WORK NEW - ALTERATION ADDITION O REPAIR MOVING DEMOLISH L7 SQ. FT.�d�/ N O.OF Z SIZE // I� ROOMSSTORIES S __ r WALL ROOF h COVERING((�CsC��' I COVERING 04---.-5s USE OF NEW () V� w�lff BUILDING I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION, /INSPECTOR 4�r�y DATE Hyl AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS, MATERIALS ��� AND STATE LAWS REGULATING BUILDING CONSTRUCTION. FRAME: FIRE STOPS, "i/�l s -� .i,�• t SIGNATURE OF BRACING, BOLTS .,t ",•i�'' �!� ;R�L• :i,n`?" '% RI3',ySI OWNER LATH, INT.: AUTHORIZED AG 7" I LATH, EXTA $ p C $ . PLASTER, INT. FEE PLASTER, EXT. VALUATION ` . :FINALI Sim FEE } 1 WORKERS' COMPENSATION DECLARATION " " w I herQby afrirm'-ihat .I have a certificate of.'consent'to self PER iT insure, or a certificate'of Workers Compensation Insurance, APPLICATION F® UIL®IN.G or a certified copy,thereof (See..3800,Lab. C.) COUNTY'OF LOS,ANGELES BUILDING'AWSA'FETY, Policy No. Company _ _ - G ❑ Cerrrfied copy is hereby furnished" FNG .FOR APPLICANT TO FILL IN ApoRESs 7g2. .LQ�M Certified.•copy is filed with the county building mspec tion department.Date Applicant ��••} l r f " ZIP: LOCALITY' e 1 CtCERTIFICATE OF EXEMPTION FROM WORKERS NOr OF 8LDG5 " -;, NEAREST, - {�COMPENSATION INSURANCE NOW ON LOT CROSS ST 1✓w ,ASSESSOR(This section need not'be completed if the permit is for one •- ed dollars ($100)o�less.) LO MAP BOOK PAGE PARCELhundr ;, BLOCKti p T•NO d /-.I certify thot.in the,performance,of rhe'work for wthis / . C_'CCI<NO: USE ZONE MAPpermit is issued, Fshall not employ any person'in any manner /�►I� IPECIAL so as to become subject to the Workers'Compensation-Laws.. �' �r$►^►A V� � CONDITIONS V - �• �/.'d ( CITY ZIP - Date Applicant Y NOTICE TO APPLICANT: If, after making s Certificate of ARCHITECT OR TEL. DIS ENGINEER NO, TRIC ONST��' ' Exemption, yov should become: subject to the Workers T GROUP TYPE ' FIRE PROCESSED B f) Compensation.provisions of the-Labor Code, you•must forth- AD 5•`� � �,. C ZONE , with comply with such,provisions or this permit-shall'be TEL. STATISTICAL CLASSIFICATION APV: �COV_ deemed revoked:` CONTRACTOR LO� i NO: LICENSED-(ONTRACTORS DECLARATION LIC. CLASS NO.. D-WELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO: (commencing with Section 7000)'of Division 3 of the Business and LIC: SEWER MAP Professions Code, and my.license is in full force and effect. TY. GLASS" BK L.PG . 4 VALIDATION SO. FT ''ll NO. OF N0, OF CHECK License Number Li&Class SIZE S1V STORIES FAMILIES ONE V NEW VALUATION O o DESCRIPTION OF WORK n Q. '�I!, Contractor Date ADD •vO n I.am exempt under Sec. Z � ©'� ALTER LU B.BP.C. for this reason .S 0 s �• REPAIR $ ❑ o f¢ Date: USE STOING BLDG. T' Y+. ' /r►L DEMOL ❑ Z APPLICANT TE . Signature 1 y^ O/ FINAL ` �/+ 9 PRINT) NO.�7-✓b� :� OWNER-BUILDER DECLARATION " DATE I hereby offi`irri that I am exempt from the.Contractors License " Law for the following reason (Section 7031.5, Busines's,oncl ADDRESS - S Ll- . L �.A (J FINA� Professions Code): Moo PRESS T /%� ' B Y !l. . -® - BUILDING . . . I, as owner of the property`.or.my employees with ADDRESS wages as their sole compensation;will do the work and .. 1 the structure is not intended or offered for sale(Sectio_n LOCALITY 7044, Business.and Professions Code)., MOVING TEL: _ CONTRACTOR NO. G - El I, as owner of;the property, am exclusively contracting with licensed contractors to construct the project (Sec- ADDRESS `> " tion 7044,'Business and Professions Code). REQUIRED TOTAL SETBACK F + 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 thispermif is issued - P.L. 20 F - (Sec. 3097, Civ: C.}. SIDE P.L. j Lender's Name" m P.C. Fee$ Permit Fee M Z S95--o6 LDMA Ref..#, a Lender's Address l.0 •. S� $ I certify that I have read this ap\ee and state that the Issuance Fee LDMA P/C# o above information is correct..l agrply with all County Investigation Fee n 0 ordinances and State laws relatiilding construction, Total Fee' 2 0 Sb LDMA Perm..#and hereby authorize represeinta . his County to enter' upo a abov e^tinned property for inspection purposes: x a / 1 SEE REVERSE FOR EXPLANATORY LANGUAGE .Signor r o •Applicant or Agent Dote - - - - _ -