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HomeMy Public PortalAbout9228 LONGDEN AVE_Building__ WORKERS' COMPENSATION DECLARATION hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, ar(a !fie co y thereofSec.3�0 b. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Po icy-l" mpa y Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING PY Y . ADDRESS Certified copy is filed with the county building inspec- BUILDING do de artment. ADDRESS - It � Date Applicant 9 CITY c ZIP %/7�� �: LOCALITY NO.OF BLDGS. NEAREST CER IFICATE 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 PARCEL hundred dollars ($100) or less.) TEL OWNER NO.LQJ�J�� NO.USE ZONE MAP I certify that in the performance of the work for which this _ SPECIAL >_ permit is issued, I shall not employ any person in any manner ADDRESS =__P� CONDITIONS a- so as to become subject to the Workers'Compensation Laws. - O Date ApplicantDe ARCHIT CT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZOf1E U Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS �� ���/ a with comply with such provisions or this permit shall beI TEL• ' STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. A CONTRACTOR p ANO. _ LICENSED CONTRACTORS DECLARATION # LIC. CLASS NO. DWELL. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS3 � �i'� p NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. p and Professions Code,and my license is in full force rideffect. CIN A • CLASS ---57 BK PG VALIDATION SQ. Fi NO. OF NO. OF ) CHECK License Numbe Lic. Class SIZE ) STORIES FAMILIES ( ONE VA DATION Contract c9J� z. DESCRIPTION OF WORK NEW ❑ [:] s ElI am exempt under Sec. C y t ADD � ALTER ❑ BAP.C. for this reason (1 -- REPAIR $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APDL c TEL FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE I hereby affirm that I am exempt from the Contractor's License ' Law for the following reason (Section 7031.5, Business and n ADDRESS zsz v a FINAL 1 Professions Code): PRESENT By ;r {BUILDINGS.I a e ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and L�I� the structure is not intended or offered for sale(Section LOCALITY ' 7044, Business and Professions Code.) MOVING TEL. CONTRACTOR _ I, as owner of the property,am exclusively contracting NO. _., with licensed contractors to construct the project (Sec- ADDRESS !COAL 93. 63 tion 7044, Business and Professions Code.) ;. p REQUIRED TOTAL SETBACK FROM EXIST. CHECK 7 v a'�, CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT CHANGE the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. _I l Xffj—iJ[t ;I 4 4, Sd:7 Lender's Name LDMA Ref. # g C it'd i, i si �+a P.C. Fee$ Permit Fee �• ® .•!_.!_ t ill I '■ l: Lender's Address . 1 certify that I have read this application and state that the Issuance Fee LDMA P/C# 3 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws to building construction, Total Fee 1_� LDMA Perm. # ere ort representatives f this County to ante - Em" J upo t a ve- entioned pr er or inspection os SEE REVERSE FOR EXPLANATORY LANGUAGE gn e o Applic nt o nt at WORKERS'COMPENSATION DECLARATION hereby affirm that I Iopve certificate of consent to self APPLICATION F®R BUILDING P E RM I T insurD, or a certificate of Workers'Compensation Insurance, or a cert' ie c th reof(Sec. 3800A�o 46d COUNTY OF LOS ANGELES BUILDING AND SAFETY Policgal 01 X y Company copy y FOR APPLICANT TO FILL IN BUILDING ��/� ertified co is hereby furnished. ADDRESS Certif'ed copy is filed with the county uilding lnspec- BUILDING L� 4Mq4yifSZ do epar ment. l ADDRESS Date 31mApplicant . CITY ZIP 1 t7 n LOCALITY CE TIFICATE OF EXEMPTIOFROM ORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURA SIZE OF LOi NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less..). TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL ,p �y USE ONE MAP I certify that in the performance of the work for which this OWNER N O[1 / NO. } permit is issued,I shall not employ any person in any manner i I SPECIAL IL so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS Date Applicant CITY ZIP IN- NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT ORTEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0 ENGINEER NO. CO ZONE Exemption, you should become subject to the Workers' c'1 Ny Compensation provisions of the Labor Code, you must forth- ADDRESS l/�G J`V R with comply with such provisions or this permit shall be O TEL STATISTICAL CLASSIFICATION APT. CONDO. g deemed revoked. CONTRALTNO LICENSED CONTRACTORS DECLARATIONLIC, / CLASS NO. DWELL UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N �7 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force an effect. CITY BK PG VALIDATION SQ.FT. NO.OF NO. CHECK License Nu ber Lic.Class SIZE STORIES FAMILI S ONE VALUATION Contractor Date DESCRIPTION OF WORK JjQ& NEW ❑ $ /.,,�� I am exempt der Sec. (�( �1r ADDALTER B.BP.C. for this reason REPAIR ❑. $ USE OF Date: EXISTING BL .!S. DEMOL ❑ Signature APPLICANT r D TEL. FINAL �� OWNER-BUILDER DECLARATION PRINT NO. DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FIN Professions Code): PRESENTBY BUILDING i I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section 7044, Business and Professions Code). MOVING TEL. I,as owner of the property,am exclusively contracting CONTRACT NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). P-6 9 4 0 A REQUIRED TOTAL SETBACK F CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH # 0 0 0 0 oil 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. 1 - - 4988 c Lender's Name LDMA Ref. p - o - 4 9.8 8 Lender's Address P.C.Fee$ Permit Fee - � 0 IL 3 0,L$7 r I certify that I have read this application and state that the Issuance Fee LDMA P/C H pop above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, and reby authorize representatives of this County t enter Total Fee LDMA perm. if upo above- entioned property or inspection p pose . D SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applin or ent bate WORKERS'COMPENSATION DECLARATION i 4 ° L'IheA:by affirm that I have a certificate of consent to self '�tspre,o;a certificate of Workers'Compenstion Insurance,or APPLICATION FO! , BUILDING P E RM I T a certified copy fh%reof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is herebytfurnished. FOR APPLICANT TO FILL IN ADDRESS Vd d ❑ Certified copy is filed with the county building inspec- BUILDING /).�� La„!G he,� tion department. ADDRESS 7 /� LOCAU Date Applicant CITY T L �' ZIP 7 NEARECROSSS T.' ��pNO.OF ASSESSOR � CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT-/�O '�K��®'�NOW ON TS � < MAP BOOK PAGE PARCEL COMPENSATION INSURANCE (This section need not be completed if the permit is for one US ZON MAP hundred dollars($100)or less.) TRACT BLOCK LOT NO. � NO. rs y- TEL. 1 ®� SPECIAL I certify that in the performance of the work for which this OWNER �0 ��'r 1-e VX NO.� � $ O`r CONDITIONS permit is issued@ I shall not employ any Person in any manner D RICT GROUP TYPE FIRE PROCESSED BY so as to become subject to the Workers'Compensation Laws. ADDRESS Z g �b e-i / CONS CITY '—p- r,- C. ZIP T CJ 7Ja 0 Date Applicant STATISTICAL CLASSIF ATION PT. CONDO.. NOTICE. TO APPLICANT: If, after making this Certificate of ARCHITECT OR YJ W (• TEL. Exemption, you should become subject to thlb Workers' ENGINEER r NO. CLASS NO. / DWELL..UNITS Compensation provisions of the Labor Code, you must forth- ADDRESS r SEWER MAP -with comply with such provisions or this permit shall be TEL. deemed revoked. CONTRACTOR d NO. BK. VALIDATION LICENSED CONTRACTORS DECLARATION LIC. (hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY CLASS SS . �� License Number Lic.Class SIZES / S TO I ES FAMIOLIES CHECK NEW E]C A $ Contractor Date DESCRIPTION OF WORK D . ElI a �.m exempt from the licensing requirements as 1 am a �}j�>F/��� r SC''(.tJ/w1 67 }-O.Z M ADD licensed architect or a registered professional engineer A ALTER ❑ FINAL I acting in my professional capacity (Section 7051, EPAIR ❑ DATE ✓? + Business and Professions Code). USE OF (',p�nl G 70-8; v + EXISTING BLDG.veYr LX f S Tl/✓ � . go, ❑ BIN Lic.or Reg.No. Date APPLICANTn TEL. �� p OWNER-BUILDER DECLARATION PRINT) R.,,3-el-t Lei/ NO.D I hereby affirm that I am exempt from the Contractor's License ' 1 •�� D N �` �' r Law for the following reason (Section 7031.5, Business and ADDRESS �. Professions Code): © 7ADDRESS / .. I, as owner of the property, or my employees with wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section 7044, Business and Professions Code). MOVING TEL. . ❑ 2 7. I, as owner of the property, am exclusively contracting CONTRACTOR O with licensed contractors to construct the project (Sec- gDDRESS ' a o o a c tion 7044, Business and Professions Code). 'REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD_. HWY PROP. LINE WIDTH ? - 111.2-00 1 hereby affirm that there is a construction lending agency for FRONT X �j the performance of the work'for which this permit is.issued P.L. C� �`� o c j ! 2 �1 (Sec. 3097, Civ. C.). SIDE r Lender's Name ,) JJ ° Lender's Address kc Fe Permit Fee l I certify that I have read this application and state that the Issuance Fee above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee and hereby authorize representatives of this County to enter upon the above-menti ned property for inspection puros s. G 411-0 SEE REVERSE FOR EXPLANATORY LANGUAGE 0 Signature of Applica r Agent ate r-