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HomeMy Public PortalAbout5746 LOMA AVE_Building__ `,y"IORKERS'.COMPENSATION DECLARATION nsure bor a{certif cairm tte.of WorkerssriCompensat on ificate of ensurancent to f " APPLICATION F , R BUILDING . PERMIT-. ow a certified'copy thereof (Sec: 3800, Lab. C.)•' COUNTY'OF.LOS ANGELES BUILDING AND SAFETY 'Policy No Company - BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL-IN ADDRESS ❑• Certified co is filed with the count buildin ins ec- BUILDING ,( / p •' PY Y. g p ADDRESS S'�u LAMA LIC ; • tion department. - - Date Applicant CITY cyt" ' C+r ZIP O LOCALITY pp `NO. OF BLDGS. ;' NEAREST _ •CERTIFICATE OF EXEMPTION FROM'WORKERS' SIZE OF LOT Now ON LOT CROSS ST. COMPENSATION INSURANCE." ASSESSOR /� (This section need not be.completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK. . . PAGE v 7 IPAIICEL 49 hundred dollars($100) or less.) TEL. OWNER t �OSc NO. USE.ZONE. MAP NO. I certify that in the performance.of The work for which this * / LOCA e SPECIAL - >- permit is issued, I shall not employ any person in any.manner ADDRESS-.1 7 6 / CONDITIONS d so as to become subject to the Workers' Compensation Laws. / 0 CITY. 8i LL Lit j. ZIP. . 6 Date Applicant ARCHITECT OR I TEL. DISTRICT GROUP ITYEESPFIRE' PROCESSED BY'NOTICE TO APPLICANT: If, after.making•this Certificate.of �{ ENGINEER NO. ZONE Exemption, you should become subject to the Workers' v eu'st � a Compensation-provisions of-the Labor Code, you must forth- ADDRESS_ J� with ,comply with .such.provisions or,this. permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO.- Z deemed revoked.- CONTRACTOR - NO. h LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. �C DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP .(commencing.with Section 7000)of Division 3 of the Business LIC' b CITY CLASS ' VALIDATION and Professions,Code,and my license is in full force and effect. ` BK. PG._ �1 SQ.,FT. NO. OF NO:OF ? // CHECK License Number Lic.-Class SIZE STORIES FAMILIES:'@Ce ONE U VALUATION Contractor Date ` DESCRIPTION OF WORK NEW ❑ b til _ AD p�' ADD ❑1 am exempt under Sec. Y N �- C�1►L �OA�L. ) ALTER $ y B.&P.C. for this reason ' ��' 1 �' REPAIR ❑ USE OF; Date: EXISTING BLDG. v DEMOL ❑ - 1 =5 J•• ^ � - Signature \V� APP PRAT l Ns. FINAL OWNER-BUILDER DECLARATION V► t t��_ / DATE I herebyaffirm that,Lam exem t'from the Contractor's license `=`J LL f r the fbllowmg reason (Section,7031.5, Business and. ADDRES / �ta-� Y�. ++t� Lt N Prpf sions Code): PRESE By I BUILDING I, as owner of the property;' or'my employees with ADDRESS wages as their sole compensation,will do the work`and LOCALITY ® t u;- the structure is not intended or offered for sale(Section ` 7044; Business and Professions Code.) MOVING CONTRACTOR " �'• x.NO.•• ❑ I, as owner of the property;*am exclusively contracting with licensed contractors to eonstruct.the' project`(Sec ADDRESS tion 7044, Business and Professions Code) EQUIRED TOTAL SETBACK,FROM EXIST .i CONSTRUCTION LENDING AGENCY ET BACK YARD HWY PROP. LINE' WIDTH I hereby affirm that there is a construction lending agency for FRONT 4 _ the performance-of the work.for which'this permit is issued P.U. (Sec. 3097, Civ. C.). SIDE. Lender's Name' m �/'lJ1 ��3� . LDMA Ref. # P.C.'Fee.$ Permit Fee -- Lender's Address ,LPoo I I certify that I have read this*application and-state thai the 7O Issuance Feer LDMA P/C# Poo 8 above information is correct..'I agree to comply.with all County Investigation Fee. oordinances and State laws relating to building construction, 1 Total Fee i LDMA Perm. # a and hereby authorize.tepresentatives of this County to enter- upon-the nterupon-the above-mentioned pf riX for inspect; urpo S. -. _ - n � SEE REVERSE FOR EXPLANATORY LANGUAGE ^, Signature of Applicant cV AgerOt Date WORKERS' COMPENSATION DECLARATION eJ I:hereby affirm that I have a. certificate insure, or a certificate of Workers'Compenstion Insurance, or t A P P L I CATION F O RBUILDING PERMIT of consent to self ; a certified copy thereof (Sec. 3800, Lab. C.)' n�" COUNTY OF LOS.ANGELE . BUILDING AND'SAFETY, . t Policy No r _Company u .?t.6, G rr A� Certified co ishereb furnished. BUILDING Q copy v FOR APPLICANT TO FILL IN ADDRESS �� ' 'Certified copy is filed with the cou y Ong inspe BUILD7S5 tion department. ADDR (,S / • LOCALITY� NEARESTDate Applicant CITY ( j/''G// ZIP / CROSS ST.% G ASSESSOR CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE-OF LOTJ�VA Y NOW ON LOTNO, OF S - '/ MAP BOOK PAGE PARCEL COMPENSATION INSURANCE (This section'need not.be completed if the permit is for one U NEI' MAP hundred dollars ($100)or.less.) - .. } TRACT BLOCK T NO. ! NOLO �/ } TEL SPECIAL tL ` hiperformance of the work far which this OWNER �r .J/7 (t/ NO. CONDITIONS I ceriif tatnthe P Y DISTRICT I GROUP. TYPE F RE P C SED BY O permit is issued', I.sholl not employ.any'person in any manner. S't���ll7C � V so ah ad s to become subject to the Workers'Compensation Laws. ADDRESS �P '. ` CONS . Z 1 CITY ZIP - Dote Applicant STATISTICAL CLAS ICATION A CONDO. NOTICE TO'APPLICANT:•If, after making-this Certificate of ARCHITECT OR -TEL. iLU Exemption, you should, became,subject to the Workers' ENGINEER NO. CLASS-NOt DWELL. UNITS H Compensation provisions of the Labor Code;.you must forth- AD SEWER MAP with.comply with such .provisions or this permit shall be // deemed revoked., M TEL. ��y/ p� BK PG� VALIDATION CONTRACTOR U /+/ ` NQLd(v 0 G-/S , LICENSED CONTRACTORS DECLARATION LIC. 3�SS I hereby affirm'that,l am licensed under provisions of Chapter,9 . ADDRESS e NO.. VALUATION ' (commencing with Section 7000)of Division 3 of the Business and �+ // a LIC. pp Professions Code, and my license is in full force and effect. CITY Jc+?/7 (.�b1-/e.I CLASSb� $ �� � _ _ C SQ. FTM�' NO.OF ,/ INC.OF' CHECK License Number I S S s�>` Lic.ClassF I SIZE 7Ul STORIES / FAMILIES / ONE /n' �j/ ,•� $ Contractor) '( ^ � Date g �� DESCRIPTION OF WORK�� j /([D!7 NEW A oADD . I am exempt from the licensing requirements as I am a Q /Yl licensed architect or a registered professional engineer r' ALTER FINAL,7_16 / acting 'in my professional capacity, (Section 7051, � DATE . REPAIR Business and Professions Code). USE OF �' /� DEMOL '� FINAL EXISTINGBLDGJ/X?el- !? /(F� B Lic:or Reg. No. Date 7. APPLICANT TEL Y OWNER-BUILDER DECLARATION; `' (PRINT) NO. I hereby affirm that I am exempt from',the Contractor's license G'C Law,for the following reason.(Section 7031.5, Business and ADDRESS Professions Code): PRESENT.- BUILDING RESENT BUILDING . 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and J the'structure'is not intended-or offered for sale(Section. LOCALITY - - 704 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- tion 7044, Business and Professions Code). ADDRESS 2'4,0'1',.-TA REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD' HWY PROP. LINE WIDTH hereby affirm that there is a construction lending agency for ; FRONT # 0'-0-o 0 oil the performance of th.e work for which this'permit is-issued P.L: .(Sec. 3097, Civ. C.). ,_ SIDE-, - - 2• 1 51,00 P.I. Lender's Name ° e,1 5 1.0 0 U o P.C. Fee$ Permit Fee / -.- Lender's Address 0.2,'Q9—8 1 . > I certify that I have read this application and state that the ssudnce Fee above information,is correct. I agiee to comply with all County Investigation Fee . ordinances and State laws relating to building construction, Notal Fee and'hereb)b. e-mentioned thorize representatives of this County to,enter, a upon t e aproperty fo'r inspection purposes. �y,.� SEE REVERSE FOR•EXPLANATORY LANGUAGE h; Ps Signature of Applicant or Agent - Date - O APPLICATION FOR BUIL®INC,PERMIT s�.'. COUNTY OF LOS ANGELES. BUILDING AND'SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN euILONG AW� BUILDING ADDRES - I hereby affirm that I have a certificate of consent to self insure, �•� t,6 or a certificate of Workers' Compensation Insurance,or a certified -! copy there fS Seca l �J CK 3800,Lab.C.) Y,e ZIP/ / y , v l 'LOCALITY Policy.NO. ltil:Z Company d q SIq OF L T NO.OF LDGS.NOW ON LOT- � Li E3 Certified copy is hereby furnished. Z't O D �,�R NEAREST CROSS ST. Certified copy is filed with th ounty building inspection TRACT BLOCK LOC N . de rtment. ' (,i _ USE ZONE MAP NO. Date �� licant ASSESSOR MAP BOOK PAGE PARCEL-- 6 –b l7—D 14 SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' ., OWNER � TEL NO. p �! COMPENSATION INSURANCE V�� P� ������a WITHIN 1000 FT.OF SCHOOL? YES NO D ESS (This section need not be completed if the permit is for one hundred ADgESS DISTRICT GROUP TYPE CONST. FIRE ZONE PROC ED dollars ($100)or less.j r I'certify that in the performance of the work for which this permit' CITY-ei . 1-4 1-7 ZIl •-.:549 is issued,'I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. Y become subject to the Workers'Compensation Laws. - - STATISTICAL CL/AAS��SIFFI�ICATION APT ONDO Date Applicant ADDRESS - - CLASS NO. L_ 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. SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith C,I r!�-dZ 6'vt C, FRONT comply with such provisions or this permit shall be deemed revoked. jDDDRESS LIC.NO. P L 1 V t SPuC-1 7 �1 SIDE LICENSED CONTRACTORS DECLARATION.. CIT` LIC.C !I� P L. I'hereby affirm that I am licensed underprovisions of Chapter.9 ''C'4''J e S�LAS a SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES .. NO.OF FAMILIES - NEW BK PG Professions Code,and-my license is in full force a effect. , a License NuK. DESCRIPTION OF WORK - ADD ❑ VALUATION - O m r Lic.Clas f 1.�=�`� � a CJ�� Contractor ��1. _ Date ALTER ❑ $ � 11I am exempt under Sec. REPAIR El $ 08 U B.&P.C.for this reason DEMOL ❑� LDMA P/C# 13 W Date: USE OF EXISTING BLDG. ('f D URM ❑ ACCT. nCT g n' Signature J '` -� LDMA Perm# (jL� �8 Z_ g APPLIC 3 1�-� s S f s s o 3. 03 55.49 ❑ 1, as owner of the,property,.or my employees with wages as . their sole compensation,.will do the work and the structure.is ADDRESS not intended or offered for sale (Section 7.044,,Business and FINAL DATE Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL - �• '° ACCT o v - ❑ I, as owner of the property, am exclusive) contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Y, Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 9 3303 108.90 licensed contractors to construct the project (Section 7044, YES❑ No I� Business and Professions Code.) ITEMS WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING '�' OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH TOTAL � �a T�'p CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES El NQ-QK CHECK 165.39 w the performance of the work for which this permit IS issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING (y O 30.97, CIV.C.) �HECK T.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS,ANGELES COUNTY CODE. CHANGE .00 w ER 2.20SESTI S . . HROUGH 2.20.140 CONCERNING HAZARDOUS Lender's Name RIALS RE RTING AND F OBTPy A PERMITfROM THE SCAQMD. - o Lender's AddressowNea oa AceNr� 0000-0001 o. .11l22/95 I certifythat I have read this application and state under penalty p - -' P.C.FEE rl / PERMIT FEE , +404 1 AM ©:56 of perjury that the above information is correct. agree to comply /_r /f /1 too_r with coun ordinances and State laws relating h building c0 U con ruction, an hereby authorize representatives of this County ISSUANCE FEEco nL � toe te�Upon above-mentioned rop for inspec'o purposes.(5, �• INVESTIGATION FEE TOTAL'FEE Signature gent Date _ SEE REVERSE FOR EXPLANATORY LANGUAGE