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Home My Public Portal About6118 MUSCATEL AVE_Building__ • WORKERS'COMPENSATION DECLARATION hereby affirm that I have a certificate of consent c self APPLICATION FOR BUILDING P E RM.I T unsure,or a certificate of Workers'Compenstion Insurance,or a certified copy thereof(F1ec. 3800- Lab C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N —Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING rj ADDRESS d Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS LOCALITY " NEAREST Date 6--oa�-�i Applicant CITY ZIP _1 CROSS ST. CERTIFICATE OF EXEMPTION FRA WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one r USE ZONE MAP ,c hundred dollars ($100)or less.) TRACT BLOCK LOT NO. �" NO. v �. TEL. ,{ ��I SPECIAL CL I certify that in the performance of the work for which this OWNER NO.o�� - CONDITIONS permit is issued, I shall not employ any person in any manner DISTRICT I GROUP I TYPE FIRE PRO SEDaY U so as to become subject to the Workers'Compensation Laws. ADDRESS CONST. ZONE S� o 11— Date Applicant' CITY ZIP STATISTICAL CLASSI CATION PT. CONDO. UU NOTICE TO APPLICANT: If, after making this Certificate of_ ARCHITECT CIR /� TEL. / Exemption, you should become subject to the Workers' ENGINEER .(�. NO. CLASS NO. / DWELL. UNITS 1A Compensation provisions of the Labor Code, you must forth- ADDRESSI SEWER MAP with comply with such provisions or this permit shall be EL. / deemed revoked. CONTRACTOR NO.�/ ,� BK• PG. 4 VALIDATION LICENSED CONTRACTORS DECLARATION ® LIC. s� I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES$�_a.2.�d NO.,t_?/II 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 � $ �S�,/mZ16 �'S,•� SQEFT. STONo. FA OF CHECK License Number �f Lic.Class �¢ � STORIES FAMILIES ONE Contractor Date a DESCRIPTION OF WORK NEW ❑ $ ❑ k ADD ❑ Im aexempt from the licensing requirements as I am•a licensed architect or a registered professional engineer ALTER ❑ FINAL 1-2 acting in my professional capacity (Section 7051, 1. 1 REPAIR ❑ . DATE Business and Professions Code). USE OF NAL (' / EXISTING BLDG. DEMOL ❑ FINAL Lic.or Reg.No. Date APPLICANT 9TEL. By OWNER-BUILDER DECLARATION (PRINT) NO. Q I hereby affirm that I am exempt from the Contractor's License Gl Law for the following reason (Section 7031.5, Business and ADDRESS #i o o o o ; Professions Code): PRESENT ❑ BUILDING 2 0 0 •' I, as owner of the property, or my employees with ;:,ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY o 0 0 7044, Business and Professions Code). MOVING TEL. 1,as owner of the property, am exclusively contracting CONTRACTOR NO. Q 6- 2 6— with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). ADDRESS REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE 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 #i (Sec. 3097, Civ. C. SIDE P.L. Lender's Name ` drnj 2 a 1 C6 , C P. . Fee$ Permit Fee 4�`��J / o a l Lender's Address '�f - r I certify that I have read this application and state that the Issuance Fee / 0 ?_ 6— 1 above information is correct. I agree to comply with all County c Investigation Fee ordinances and State laws relating to building construction, Total Fee and hereby authorize repre entotives of this County to enter I up the above-menti p operty for inspection purposes. _ SEE REVERSE FOR EXPLANATORY LANGUAGE D Signature of Applicant or Agent Date ®s APPLICATION! FOR UIL®ING PERMIT COUNTY OF LOS ANGELES "• BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUIL DI G ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILD ADDRESS ��/ ✓Q � G,�SCte Ir/� or a certificate of Workers'Compensation Insurance,or a certified CITY ZIP (�i C c/� copy thereof(Sec.3800,Lab.C.) C� 77r LOCALITY Policy No. Company SIZE OF LOT NO.OF BLDG .NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO department. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TWO - TE NO. COMPENSATION INSURANCE —�3 WITHIN 1000 FT.OF SCHOOL? YES No (This section need not be completed if the permit is for one hundred ADDRESS dollars($100)or less.) (q.-t DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY CITY ZIP I certify that in the performance of the work for which this permit " �77,r �` is issued, I shall not employ any person in any manner so as to ARC_MwagHITECT ORE INEER ` TEL NO. become subject to the Workers'Compensation Laws. STATISTICAL CL�qSIFICATION APT CONDO Date YRpplicant �� ^ )e2l ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTO}}�� TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith L pl/i c �l9 f� [.cZ�-f ' ,�r FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC. o. Q PL 3 1d � CCA gS/- ,p a?, SIDE LICENSED CONTRACTORS DECLARATION CITY \!/ LIC.CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 �lL u SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SI NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. 4.9 i NEW ❑ K PG a 'C/ Q DESCRIPTION F WORK ADD VALUATION ® 'is i_ ! a S License Number Lic.Class a(3 _ 0 ^_ Contractor Date �c b 4 "��,CI ALTER ❑ $ 37 �' 3 I' _ _ U ❑ I am exempt under Sec. REPAIR 11 ,. i : ._'i,: Q NLDMA P/C# U I .&P.C.for this reason t,A � � 9-!ft DEMOL 11 LDMA S i-z E=r�� Ba 50 V USE OF EXISTING BLDG. Date: URM ❑ 1_i-1ED zI_.CI�� Signature APPLICANT(PRINT) TEL NO. LDMA Perm# a 9 - Z ❑ I, as owner of the property, or my employees with wagesas Z their sole compensation, will do the work and the structure is`' C ADDRESS O not intended or offered for sale (Section 7044, Business and FINAL DATE Professions Code.) C C"� _p HALL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ✓ J ❑ I, as Owner of theproperty, am exclusive) contracting Wit OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EOUAL TO OR GREATER THAN THE J i�� ^, Y 9 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 'r-i5 1 Ari licensed contractors to construct the project (Section 7044, YES❑ NO❑ Business and Professions Code.) t WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH At'ti•;Q CONSTRUCTION LENDING AGENCY COAST AIR OUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ No❑ '`"' li=�O c,1 the performance of the work for which this permit is issued(Sec. rti 1 _ I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING _ T 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, 'J N TITLE 2,CHAPTER 2 20 SECTIONS 2 20.100 THROUGH 2 20 140 CONCERNING HAZARDOUS1 —a Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD I t E` tL� c66 C3 Lender's Address O OWNER OR AGENT o I certify that I have read this application and state under penalty r •, -c o P.C.FEE PERMIT FEE �• / i-I441.3G d of perjury that the above information is correct.I agree to comply 11(_ CM with all county ordinances and State taws relating to building 9 construction, and hereby authorize representatives of this County ISSUANCE FEE ��.�/O ato enter upon the above-menti ned property for inspection purposes. TT \� 10 INVESTIGATION FEE n � m , y TOTAL FEE v i}� h figrlluro 01 :cM a Aim Dec Art SEE REVERSE FOR EXPLANATORY LANGUAGE