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Home My Public Portal About4700 F MILLER DR_Building__ a,(ORKERS'COMPENSATION DECLARATION r uaffirm that I have certificate of consent self insure;orla certificate of Workers'Compensation Insurance, APPLICATION F R BUILDING PERMIT 0'a certified copy thereof (Sec. 3800, Lab. C.) I COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING �� jl /• ❑ Certified copy is hereby furnished. I FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- ' BUILDING V OO h� tion department. ADDRESS 1 '�/`+ Date I ■ Applicant CITY ZIP LOCALITY G NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTIO ROM 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. MAP600K �SQ PAGE PARCEL/,::;L hundred dollars ($100)or less.) ! 4OWNER TEL. t� 43.00? USE ZONE MAP 1 certify that in the performance of the work for which this No. w I�,� SPECIAL r permit is issued, I shall not employ any person in any manner ADDRESS .. A•�oS I/ • CONDITIONS o so as to become subject to the Workers'Compensation Laws. O CITY EL64NOZZCaA ZIP 91 "1.31 Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PR CESSED BY O ad NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER, NO. CONST.' ZO R Exemption, you should become subject to the Workers' 9 t/ U Compensation provisions of the Labor Code, you must forth- ADDRESS -D� �' !/ a- with comply with such provisions or this permit shall be TEL. Z deemed revoked. P CONTRACTOR NO. STATISTICAL CLASSIFICATION APT. CONDO. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWEU.. UNITS — I hereby affirm that I'am licensed under provisions of Chapter 9 ADDRESS Sa•�o-r► NO. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP 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 STORIES FAMILIES ONE • VALUATION ' Contractor Date i DESCRIPTION OF WORK NEW $ 80o Qa ADD ❑ V�J ► ❑I am exempt under Sec. � � ALTER ❑ B.BP.C. for this reason � REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL p OWNER-BUILDER DECLARATION (PRINT) NO. DATE/2 _IiF.'5?/ 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By ❑ I, as owner of the property, or m employees with BUILDING ° 1 8 P P tY� YADDRESS � n'''v' 'i 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.) I MOVING TEL. CONTRACTOR NO. f !TEM- I,as owner of the property,am exclusively contracting I with licensed contractors to construct the project (Sec- ADDRESS FAL tion 7044, Business and Professions Code.) r- REQUIRED TOTAL SETBACK FROM EXIST. •it: CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT CHANGE NGE •)_li the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. CILLI 1--1 f 1 .t'% s.'`' Lender's Name i �� t: $ i LDMA Ref.# P.C. Fee$ Permit Fee , )_' 1 tl i Lender's Address ; AI`• ° 1 certify that I have read this application and state that the I Issuance Fee T LDMA P/C# 0 above information is correct.I agree to comply with all County Investigation Fee XC7 Q ordinances and State laws relating to building construction, Total Fee 0 �� ..J LDMA Perm. # and hereby authorize representatives of this County to enter I ue b ove-mention=roperty r inspection purposes.6- I SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Applicant or Agent Date PPLICATION FOR -W&DING PERMIT • COUNTY OF LOS ANGELES, BUILDING AND SAFETY _ ' WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUI DI A RESS ,A �� I hereby affirm that I have a certificate of cones t to self insure, U or a certificate of Workers'Compensation Insure ,or a certifiedILL LQ.. oQa� (SQcLab.C. CI ZI ` LOCA4�4(-- f _ C�-� Lt Ey zm• Company SIZE OF LOT NO.OF BLDGS.N ON LOT / LZ-. ❑ Certified copy is hereby furnished. /7-�I/ rte. NEAREST CROSS ST. Certified co is filed with the ocuntyb ' Ins ection TRACT BLOCK LOT NO.PY 9 P USEZONE MAP NO. apartnt. �/�Date e ��Applicant ftN R Mme/P BOO PAGE 3 D PARCEL ' SPECIAL CONDITI NS CERTIFICATE OF EXEMPTION FROM ORKERS' OWNER t.:.� i TEL WITHIN 1000 FT.OF SCHOOL VJ YES NO COMPENSATION INSURANCE(This section need not be completed if the permit is for ahESS undred DISTRICT GROUP TYPE CONSTFIREZONE PROCESSEDBY dollars($100)or less.) � ZIP / rh-� //��I certify that in the performance of the work for which this pe tQ/V �� [ ` `� c„J 1 0 is Issued, I shall not employ any person in any manner so as to ARCHMECT ORE INE G TE N O become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant A RESSze CLASS NO. do"42 DWELL UNITS NOTICE TO APPLICANT: If, after making this Certificate of REQUIRED TOTAL SETBACK FROM n., Exemption, you should become subject to the Workers' CO OR TEL NO. SET BACK YARD HWY PROP LINE Compensation provisions of the Labor Code,you must forthwith FRONT 26 comply w',h such provisions or this permit shall be deemed revoked. ADD Ess ^ LI PL .•�. r SIDE s't`•`'1'a LI ENSED CONTRACTORS DECLARATION CITY L PL -7 *Ihereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP -V SO.FT.SIZE NO.OF STORES NO. FAMILIES ";'•�T�'� � (commencing with Section 7000)of Division 3 of the Business and NEW BK PG "` I Professions Code,and p license is II force and eff C� ESCRIPTIO OF WORK �l ADD ❑ ��TIO , I' �- 1 '`�=�°!'++' License Number L� Lia Class \ cfo A4 A4 L. ( (1 1- C.1 ,3�.{ ?& Contractor •��r_rz Date �,�� ALTER ❑ 1= j' - �_ `�` ❑ I am exempt under Sec. REPAIR ❑ pQ�"�Q, did - B.BP.C.for this reason L!•/�� DEMOL ❑ LDMAPIC## a ! USE OF EXISTING BLDG. URM ❑ I_f liLi 1-I iE ),j y W/1 U'' Iv Date: � 77 - ' Signature AP LI NT PRIAIfII T LDMAPerm# Z i_' < cilli=)"2- ❑ 1, as owner of the property, or my employees with wages a3 j O their sole compensation,will do the work and the structure is ADDRESS AlfOPVI not Intended or offered for sale (Section 7044, Business and FINAL ATE {l/' .G/j/I Q Professions Code.) WILLTHEAPPLICANTOR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL { t_t G 4 / a OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN ❑ 1, as owner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL lot Y ') licensed contractors to construct the project (Section 7044, YES❑ NO❑ Business and Professions Code.) O, WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING '(f OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH A 1� CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST 'pV 11 FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ No El the performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE-SCAQAi1D •.f- �•9 ' t i r..•j ' ! r. 3097,CIV.C.). PERMITTING CHECKLIST.1 UNDERSTAND MY REQUIREMENTS UNDER THE LOS'ANGEI:ES 7.''• 1_ -i( i'e COUNTY CODE.TITLEZ CHAPTER 220 SECTIONS 220.100THROUGH 2.20.140 CONSERMNG •'.- f-' s' - •i 'e Lenders Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. Cit r F- Lenders Address a,,ERO,,,aE„r — �:: , o I certify too I have read this application and state that the above �. inform is rrect. I agree to comply with all county P.C.FEE PERMIT FEE r;; ordin d to lzertyforinspectl.n relating to building construction,and here hori reptetives of this unty to en upo �� ISSUANCE FEE th o me Toned purposes �'7'T• IA-"� "' -.1 1--' a.» !�`. r rt 4; INVESTIGATION FEE TOTAL FEE +"+ SEE REVERSE FOR EXPLANATORY LANGUAGE