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Home My Public Portal About9453 LONGDEN AVE_Building__ WORKER?COMPENSATION DECLARATION.. I hereby affirm,)hat I have r certificate ns consent to self APPLICATION FOR BUILDING P E RM I T in or a certifimte of Workers'Compensation Insurance, or a certifled copy thereof(Sec. 3800,Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILD _ ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified ,NG 3 ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 0,1q Joao &r Date Applicant CITY ` ZI 7 LOCALITY 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 PARCEL hundred dollars ($100)or less.) OWNER LC Np,�fr USE ZON . MAP I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in any manner ADDRESS L �/ CONDITIONS CL soas to become subject to the Wo r 'Compensat' Laws. p OO CITY C} ZIP I 1 o to Z�Applicant ARCHITECT OR TEL. DIST UP TYPE FIRE ��CESSED BY 0 NOTICE TO APPLICANT: If, a er ma ing f is ertificate of ENGINEER NO. T. Exemption, you should become subject to the Workers' D W Compensation provisions of the Labor Code, you must forth- ADDRESS ,/�, N with comply with such provisions or this permit shall be67 TEL• STATISTICAL C ICATION PT O DO. Z deemed revoked. CONTRACTOR NO. _ LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 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. and Professions Code,and my license is in full force and effect. CITY CLASS BK. PG. VALIDATION SQ. FT. NO.OF NO.OF CHECK License Number Lic. Class SIZE I STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WOR ° NEW $ D El am exempt under Sec. ADD El ► ACCT°v ALTER ❑ "F2 B.BP.C. for this reason REPAIR ❑ $ j+� �-i��°� Date: USE OF EXISTING BLDG. DEMOL ❑ , 1 1TEM3 Signature APPLICANT TEL. FINAL123 OWNER-BUILDER DECLARATION (PRINT) NO. t;„ TOTAL a `"°t.v DATE I hereby affirm that I am exempt from the Contractor's License V/ CHECK 70 Law for the following reason (Section 7031.5, Business and ADDRESS FINAL L` Professions Code): PRESENT BY CHANGE °111 ❑ I, as owner of the property, or m employees with BUILDING P P Y� YADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY OV LIT TEL. , 0`I0`~01101 2/13/90 7044, Business and Professions Code.) ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. 93896 1 AM 8.". r with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAL SETBACK LINE FROM 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$ Permit Fee � Lender's Address ► 0 1 certify that I have read this application and state that the issuance FeeLDMA P/C p above information is correct. I agree to comply with all County 0 Investigation Fee ordinances and State laws relating to building construction, Total Fee LDMA Perm. p and hereby authorize repres fives of this County to enter Raw on the above-mentione op for inspection purposes. / / _-J, SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dote 0WORKEff4r COMPENSATIONgDECLARATION fs reby oIirm�hat I fiav p cer ificate of consent to self APPLICATION FBUILDING PERMIT insure, or a certificate ofsNorkers''Compensation Insurance, or 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 Y ADDRESS ❑ Certified copy is filed with the county building inspec- a ADDRESS 7S3 �.aFJ Ci V' :a DI tion department. Date Applicant `CITY AI,T L15 zip 17 fy LOCALITY NO.OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' .'SIZE OF LOT T`7 Z�� NOW ON LOT NEAREST 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.) y� TEL, y,OWNER ( KC- Gf- NO. USE ZONE IMAP I certify that in the performance of the work for which this _ 1b a NO' permit is issued, I shall not employ any person in any manner ADDRESS (Z 600 VOU MGA�X;DW v`' SPECIAL so as to become subject to the Workers'Compensation Laws. y� p ! CONDITIONS O CITY >i3D� (2A ZIP I d V Date Applicant ARCHITECT O TEL. �I j' NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NAFV:SQ- NO. Z%1-4�{t DISTRICT GROUP TYPE FIRE PROCESSED BY O CONST.V ZONE (•- Exemption, you should become subject to the Workers' w Compensation provisions of the Labor Code, you must forth- ADDRESS SMP C 1T �., F ,Q ._ a- with comply with such provisions or this permit shall be .TEL• ' STATISTICAL CLASSI KATION APT. CONDOto deemed revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION ' LIC. CLASS NO. CS;y]( DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 i ADDRESS NO. (commencing with Section 7000)of Division 3 of the BusinesLIC. SEWER MAP 23 s CITY CLASS ?(,\and Professions Code,and my license is in full force and effect. gK (,PG. rr��/�I IDATION SQ. FT , NO OF { NO.OF CHECK ACCT License Number Lic. Class SIZE I�+ STORIES t FAMILIES ONE 33�0�} 587.15� is T DESCRIPTION OF WORK &G Qr NEW ❑ ��' VALUATION 'Jr7i77 y ° tit Contractor Date $ 1 ITEMS ❑I am exempt under Sec. �7QPt �C.Ap &Ai2,4&e ADD ❑ TOTRi. o B.BP.C. for this reason 1kMo MOW �S00VQL8 �F(SMO U ALTER ❑ $ //��j+y CHECK O USE OF 15 REPAIR ❑ ' q 00® 0 o CHECK ,087.1rt Date: ? EXISTING BLDG. NC�fS DEMOL ❑ 'x I/jJ ° CHANGE 0I3 Signature {.APP(PRI T)ICANT � ��, D tj NO• 1 3 FINAL ° OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS �Z t '{7�t�1 M+rti�w '1�2, C1UAR�EH DDQO-[�Of $� U/3�r Law for the following reason (Section 7031.5, Business and FINAL Professions Code): PRESENT BY BUILDING 499 i RI�iQ:.Si ❑ I, as owner of the property, or my employees with ADDRESS VV wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. -3 ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. ACI 1f ICT 4 with licensed contractors to construct the project (Sec- ° ADDRESS tion 7044, Business and Professions Code.) 3307 SI]7 w!V°I1ti! REQUIREDT CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOTAL SETBACK FROM EXIST. EMS I hereby affirm that there is a construction lending agency for FRONT PROP. LINE WIDTH Z ITEMS the performance of the work for which this permit is issued P.L. TOTAL 86- 05 (Sec. 3097, Civ. C.). SIDE - it P.L. u s -� C2 ; r-` CHECK 80, 01.5 Lender's Name p` r ' 9 M --q C=' t B P.C. Fee$ /•/� Permif Fee79 MA Re .r, V 1 C iA`'GE °CO Lender's Address / I certify that I have read this application and state that the 4 vQQ��• O Issuance Fee V° 5 MA P/C# 9 comply Y dInvestigationUDCC�-JCQ 1 /rGi 1= above information is correct.I agree to Com I with all Count Fee ordinances and State laws relati to building construction, Total Fee • LDMA Perm. # = an hereby authorize rep s es of this County to enter �� 1 FTM 8:37 9�@ bov i r ert��r ins ction purposes. ~. -pry R Cfu O '� f�¢�:>C! �� SEE REVERSE FOR EXPLANATORY LANGUAGE co �� r {~.i �jj 13 Signat r of Applicant r Agent Date r�� {�1 {.ri