HomeMy Public PortalAbout9420 LEMON AVE_Building__ �� WORKERS' COMPENSATION DECLARATION
affirm that I have a �ertificate of sure'bor a certificate of Workers' Compensat on eInsurance,nt to l • APPLICATION. F O_R= BUILDING PERMIT
o cerhfie'd copy,thereof (Sec 3800, Lab C) COUNTY OF LOS"ANGELES BUILDING AND SAFETY
olc N Company1 e'L
'Cert. i�Weripby'furnished - -��_c FOR APPLICANT TO FILL IN ADILDING
DRESS M '
-� /dZ ADDRESS t7CJ
❑ Certified copy is filed with the county building mspec_
BULDINGSjqq -
?ion department. ADDREyS�S c0
~' CITY l'JaYt+�- Ci ZIP. y LOCALITY C.
Date �JL Applicant • . ' NO OF BLDGS _
CERTIFICATE OF EXEMPTION FROM WORKERS"- SIZE OF LOT NOW ON LOT NEAREST
R
' CROSS ST
COMPENSATION INSURANCE ASSESSOR,
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP_BOOK,, PAGE PARCEL
hundred dollais ($100) or fess )_ '4 TEL
OWNER OctNO USE ZONE-' MAP
NO
I certify-that in the performance of the work for which this '_ ~ SPECIAL a
permit is-issued, I shall not employ any person in any manner ADDRESS `? (i CONDITIONS CL
so,as to become subject to the Workers'Compensation Laws _ U
CITY r i� ZIP "
Date Applicant ARCHITECT OR• TEL DISTRICT -GROUP ITYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT, Jf, after making this Certificate of ENGINEER NO CONST Z NE �•
Exemption, -you,should become sublect to .the 'Workers' �Cw
Compensation provisions of the Labor Code, you,must forth' ADDRESS' - ✓ N
iwith 'comply with such provisions or this permit,shall be STATISTICAL CLASSIFICATION APT CONDO Z
.deemed revoked CONTRACTOR n/0 —
LICENSED CONTRACTORS DECLARATION UC / CLASS NO DWELL UNITS
NOJI hereby affirm that I am licensed under provisions of Chapter 9 _ ADDRESS 916 ifL1[,C LIC�lo�j� SEWER MAP
(commencing with Section 7000)of,Drvision 3 of the Business LIC �
and Professio6s Code,and my license is in full force and effect CITY • � �_, CLASS J BK PG VALIDATION
,.-: SQ FT NO OF NO OF CHECK
License Number �/akS"f Lic'rClass =3� SIZE STORIES FAMILIES ONE
. . L VALUATION
Contractor (Date _ DESCRIPTION OF WORK NEW ❑
' `- _-' ADD � '❑ s � OVOI ► _
` ❑I am exempt under Sec _���� 1' L�S 5.
ALTER ❑
B&P C for this reason 1 ►�+ts REPAIR ❑ $
Dat USE OF
_ EXISTING BLDG DEN10L'❑
Signature _ APPLICANT TEL 1c; 3 FINAL' 9l
OWNER-BUILDER DE LA ATION (PRINT) E l NO l�44��j DATE /vv/
I hereby'affirm that I am exempt from the Contractor's License gDDRESSs� 6 i U E L- WtiD4Z'� , FINAL
'Low'for the following reason (Section 7031.5, Business and /i
Professions Code). ,- . PRESENT - BY`
❑ BUILDING _
.11. LT as owner of`the property, or,rny employees with ADDRESS
wages-as their sole compensation,
will do the work'and
LOCALITY i )_,.4.t
' the structure is not intended or offered for sale(Section - ,
7044, Business and Professions Code MOVING -- TEL - •r f=ir
D,l Et l:
❑ I,as owner of the property: am exclusively contracting CONTRACTOR NO c
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions,Code ) t� c. -.
REQUIRED TOTAL SETBACK FROM'" 'EXIST . (.`HE4J` �E I-' i•`'.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH'
I hereby affirm that'there is a,construction lending agency for FRONT w tIP� �
the performance'of the work for which this'permit•is'issued 'PL
(Sec 3097, Civ C•) SIDE y
Lender's'Name PL ii�
LDMA'Ref• # s
r _ PC.Fee$ Permit Fee
'Lender's Address ,
o I certify that I'have read this application,and state that the Issuance Fee �� 1 LDMA P/C#
8 above information is correct ,I agree to comply with_all County Investigation Fee _
ordinances and'State jaws relating to building construction, Total Fee �/OI L)MA Perm'# ^
a and hereby authorize representatives of this County to enter -
upon the ave-me toned pt for for inspection purposes '
g/J�/ �hS+ _ EE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Apphcdffit Agee Date
76A638A CE#803 8-63 APPLICATION FOR BUILDING PERMIT LJ h
COUNTY OF LOS ANGELESBUILDING �/ E
DEPARTMENT OF COUNTY ENGINEER ADDRESS �/'��
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A JENSEN, SUPT OF BUILDING CROSS ST
DISTRICT NO GROUP TYPE* P CESSED BY
FOR APPLICANT TO FILL IN -� cONSr
BUILDING n r STATISTICAL CLASSIFICATION S WER MAP
ADDRESS47Z yrs v It��� BK G
CLASS NO DWELL UNITS
LOT NO ��LJ BLOCK WATER ❑ �%
J ^ CERTIFICATE NOT REQUIRED RECEIVED
TRACT r .119* r MAP HIGHWAY
NO OF BLDGS NO 16) ICIRCLE) STATE MAJOR SECON LO
SIZE OF LOT Z/f y^ NOW ON LOT USE ZONE SPECIAL n
USE OF CONDITIONS 'C� 07 /L/
EXISTING BLDG
TEL
OWNER NO N
U LDIG YARD HWY T /ET NAME EXIST
�0 SETBACK WIDTH
ADDRESS FPR OL T l
ARCHITECT O T L
ENGINEER NO SIDE
ADDRESS TEL �/ Q
CONTRACTO NO�31]103 t J J � ' J 'r
ADDRESS 6 10
DESCRIPTION OF WORK'
ADD ALTER REPAIR DEMOLISH
SQ FT NO OF NO OF /! (L 1 IKi A_ Z
SIZE STORIES FAMILIES
USE OF
STRUCTURE
Air-
SIGNOATURE O .1910�
✓✓ i�°'�`�" �4S?' 1� 1,
APPLICANT
VALUATION $ ��� MhpA��`�.�/
11
r
APPROVALS I DATE INSPECTOR'S SIGNATU 9
P C PMT // FOUNDATION LOCATION /I
FEE $ FEE $ �T 3 FORMS MATERIALS G
FRAME FIRE STOPS
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS
' BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE WORK - ..
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH INT
TION OF THE LABOR CODE OF THE STATE CALIFORNIA RELAT.
ING TO WORKMEN S PE TIO N E �� Yr 9• -
LATH EXT ♦7A
SIGNATURE O HOUSE NUMBER COR- _9
//.�.+�►"
PERM ITTEE RECT AND POSTED /�y7
ADDRESS FINAL -
PLAN CHECK VALIDATION cK MO CASH JOHN_F,LEWIS PR CIP LST C RAL ENGINEER
PERMIT VA', CK
LIDM O CASH
y 0 NOV 6 2 3 D 3 7 2 5 4•
L 60 3 3 NOV 19 1 D7 4.50- 4T