HomeMy Public PortalAbout6133 MUSCATEL AVE_Building__ WORKERS' COMPENSATION DECLARATION
, e,.o affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT
certified insure■or a certificate of,Workers' Compensation Insurance,
or a 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 ADDRESS
❑ Certified copy is filed with the-county building inspec- BUILDING
tion department. ADDRESS-� 3 US ,
Dated Applicant CITY , �p�l ' zip 77. LOCALITY
CERTIFICATE OF EXEMPTI N FROM WORKERS' / NO,OF LOT NEAREST
r. SIZE OF LOT (� NOW ON LOT CROSS ST. rLD Z,06.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT y�� BLOCK LOT NOS Q � MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) TEL' US O E MAP
OWNER '1 t/ NO. NO. ISO AM&
I certify that in the performance of the work for which this r �x
SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS fes. n ��� � ���G7 . CONDITIONS c
so as to become subject to the Workers'Compensation Laws. / `
4-4-209 . n�/A}— CITY �'1T/� ��'�/�� 1�— zip /77T_
Date Applicant V�� ARCHITECT OR `T. L 4j4 TEL. DISTRICT GR UP TYPE FIRE PROCES D BY �
NOTICE TO APPL CANT:.If; afte making this Certificate o ENGINEER •L NO. 6-73-1410. CONST. E H
Exemption, you.should become subject to the Workers 1� CA _ f u
Compensation provisions of the Labor Code; you must forth- ADDRESS 1004-X, C7 gds P' _C111 7, 5i L a
with comply with such,provisions or this - STATISTICAL C FICATION APT. CO D v
p y p permit shall be 'TEL. ..,may
deemed revoked. CONTRACTOR u� 5TL NO. l/O �'D 2
LICENSED CONTRACTORS DECLARATION -� � C. CLASS NO. DWELL. UNITS
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ""'O• 3 0 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business CITY � �' LIC.
and Professions Code,and my license is in full force and effect. 9 CLASS BK PG. �/V VALIDATION
SQ. FT NO. OF NO.OF CHECK
License Number 1 e jV SIZE Zn STORIES FAMILIES ONE -
�5�I �� �" Lic. Class ���!!! VA UATION
Contract or_�r7+ d� � �Da 6�Z' •y DESCRIPTION OF WORK 57M 06 N ""-"' - -`� ''-'j
❑I am exempt under Sec. rj( L)Z fwd ADD , ='i^-
ALTER ❑ / -!- •--•0
B.BP.C. for this reason REPAIR ❑ ; / f (°J\--�, i:; ,•?:,
Date: USE OF
1 EXISTING BLDG: DEMO ❑
-��-+` " APPLICANT TEL.
Signature ^�i �$
g WNER-BUILDER DECLARATION (PRINT) ]� ) Vy�v NO. "d ✓�d8 DATE`
I hereby affirm that I am exempt from the Contractor's Li se .. ,y
Law for the followingreason Section 7031.5, Business and ADDRESS 8 .� �i. � AIKL ul ,s 9f FINAL "i_";r-�:i;�l� rr;r•
Professions Code): PRESENT By
BUILDINGEl I, as owner of the property, or mYlem to ees with ADDRESS
wages as their sole compensation,wil ---
_ iii!��•_ :.:,
do the work and
the structure is not intended or offered for sale(Section LOCALITY , ACCLAT,
7044, Business and-Professions Code.) MOVING TEL.
❑ •1,as owner of the property,am exclusive) g CONTRACTOR NO. 3307 .. 1180 j��i
p p y, y contracting Twat I
with licensed contractors-to construct the project (Sec- ADDRESS 1.`1`Gtt ..
tion 7044, Business and Professions Cos e..)
REQUIRED TOTAL SETBACK FROM EXIST. ` y O
CONSTRUCTION LENDING AGENCY SET BACK ARD HWY pROP. LINE w T TOTAL 110.0.05
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• ® ,\ CHECK 1150■0`� '
(Sec. 3097, Civ. C.). SIDE
P.L. CHANGE
Lender's Name
LDMA Ref. #
P.C. Fee$ s ermit Fee OODD-0001 b/12/8r
Lender's Address (� / _ , VtF
I certify that I have read this application and state that the Issuance Fee 3903 1 AM 9:32
3 above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, I Total FeeD LDMA Perm. #
and hereby authorize representatives of this County to enter
up the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature e of Applicant or A t Date '
wWORKERS' COMPENSATION DECLARATION '
hereby affirm that I have certificate of consent to self P L I CATION FORBUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copythere9f (Sec. 3800, Lab. C.)
J,4 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.
24)?
� Company_IMTM�'��
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed witIthneu nty building i BUILDING
tion ep tment. ADDRESS =
Date Applica® a�i�/ CITY' ZIP { LOCALITY
l NO.OF BLDGS. NEAREST
CERT KATE OF EXEION 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.) EL.
OWNER �•-�, N USE ZONE MAP
I certify that in the performance of the work for which thisNO. C�
permit is issued, I shall not employ any person in any manner ADDRESS p 1 SPECIAL >_
/\
so as to become subject to the Workers'Compensation Laws. CONDITIONS a-
t O
CITY' r!� CL ZIP
Date Applicant ARCHITECT OR TEL. pISTOld
RICi GROUP TYPE FIRE PROCESSED BY 0
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. �,� V CONST. E O
Exemption, you should become subject to the Workers' ' ev 7 /\
Compensation provisions of the Labor Code, you must forth- ADDRESS (��(—J
with comply with such provisions or this permit shall be EL. STATISTICAL CLASSIFICATIONL APT. CONDO. Z
deemed revoked. CONTRACTO �J� Waal.
NO. Q� / _
LICENSED CONTRACTORS DECLARATION // ' LIC. CLASS NO.C� DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 6 �VLa� NO._�5% 6 2
LIC. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business � CI a �Z /��allr� CLASS Q—�. ('}
and Professions Code,and my license is in full force and effect. BK. PG. `T VALIDATION
SQ. FT. NO. OF NO. OF CHECK 1 1
License Number Class `2
SIZE STORIES FAMILIES / ONE VALUATION •h - 3 f'7
El •3Coniracto �e DESCRIPTION OF WORK NEW E]
I am exempt under Sec. �.� S ADD ❑ $ .F� . 3-� o o
�/fl �,•
ALTER ❑ ® t 1 7 d• ?
B.&P.C. for this reason REPAIR ❑ $
Date: ;USE OF r C� DEMOL Elw EXISTING BLDG.
Signature 5 APPLICANT TEL• � FINAL �J
OWNER-BUILDER DECLARATION (PRINT L SI/� c �C�NO, •c 7 , D___ /" -Z G 7
I hereby affirm that I am exempt from the Contractor's License 0� 1 c Ai€
Law for the following reason (Section 7031.5, Business and ADDRESS.S�r�
Professions Code): PRESENT y
❑ I, as owner of the property, or m em to ees with BUILDING r'�•
P P Y� Y P Y ADDRESS 1�4t.t°v
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY aaQ7 60.C510
7044, Business and Professions Code.) MOVING TEL.
I,as owner of the property,am exclusively contracting
CONTRACTOR NO. 1 ITEC
with licensed contractors to construct the project (Sec- gDDRE55 TOTAL �'�o 30tion 7044, Business and Professions Code.)
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY CHEMSET BACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT MAKE
the performance of the work for which this permit is issued r P.L. A-1
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name, P.C. Fee$ Permit Fee 031110_ � .5/Imp
LDMA Ref. #
l
Lender's Address 1� s 3412 1 gn
1 certify that I have read this application and state that the Issuance Fee v •, b LDMA P/C#
above information is correct.I agree to comply with all County Investigation Fee
ordinances and State laws rel ' to ilding construction, Total Fee ' LDMA Perm. #
= and her by authorize repres ry this County to en r
° upon ove-mention • ape or inspection urp s
0 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App icant or ent to
a
f
DEPARTIENT OF BUILDING ANDS ~ - '� ''
AFETY,' ..APPLICA mi; FOS PERb=.v J'
COUNTY OF LOS ANGELES q ••-Y .
witt. .�. Fox. oHltr e+Iolw:tn L' ' U I L D ` N G
FOR APPLICANT TO FILL IN ": FOR OFFICE USE ONLT
RUf1
e P �, DIDTwI T NO. PLAN 6K.NO.
Aooatw J 11 . . d� P[wMIT NIL
LOCALITY ' .. o
MCC ICO MY
NG
wcWT vI v / o ���'� e,. OAT[OrAPPL. DATE ISSfIED i
w a .... J,{ •..
OWNER 'Sy".wA�fp >> IO , a: e0. RUILDINO•
- -i •1 _ _ ..+� ••.:pi4 ADDRESS
MAIL, E( ��// �g • �°
ADDRLf30MCAWCST
6'+011. ^L R�I , ~ Y` �.�q7• C L ��C ` .. S 4
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CITY • i �.�; / NA.� Tp!!4;A cacao OT •.-1,'
ARCNITt"QWrIW[• �•..• MQ SP
[NOIMEEW , TEL` '.t-# YON! PLANEs•� �• A OROUta, � 1
BLDG. r g 9
wtff `k:4. DCTSACKLIMC .r P /. /^ /!1.04116 NIL
CONTWACTOWe" fll%-1YCL. - APPROY[O0106
' aTY
IIS!Lr Dormj
OC= IFTICW LQT N I SLOG �"` 4 .q, i,
e ® CORRECTIONS
TRACT A.lJ� �v •
—AMC Or LOT ` 0 ^;0 I Mo,or RLDo
IIS[Qr r• M01w ON LOT F.d _ _ •_ -
z =."-DESCRIPTION OF WO.R$
NcW -' ALTcwarloN woorrlQN •yu4
REPAIR •°' •�':'i
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P NtIP[SY ACKNOWLCDO! THAT I NAV[ SCAB, TTfIS `.•'T 'D
APPLICATION AMD STATE THAT THC ASov[ 18 CO[:AC:T- •' APPROV � ----^ ;�
AND AOR[!TO COMPLY WITH ALL COYNTY ORDINANCES rOUNDAT10Nt LOGT�II ,f OTOfE" ._p/►T[
AND STAT!LAWS [OULAT O■UILDI .ra....MATERIAL! ♦♦ a T
7RCOMSTRUOT•I //.fir•i/} 3.
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.: •'. P.O.O+ PiJ1STER.INT. '• •• +3w ••L*: 4 e'4l�^s�t•
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DEPARTMENT OF BUILDING AND SAFETY
■� V
MFFT i .---A . Jw.w••e
' COUNTY OF LOS ANGELES
#I,= _ •: APPLICATION FOIL PERN'QZ
W1d. J. Foxe CHIEF WOtNRl11 o '%'`L _
_�.BUILDING
FOR APPLICANT TO FRL IN IISS ONLY
a.re •.*�=:t FOIL III `
BADDIII
UILDING [MSTRICi N PLAN CIL N0. .
.- 'P'L!:ItfT NQS =
• 6 0
LOGLIIT Msmvzo tY
DAT!OF APFL OAY!NItU[D �.
MAIL
-- CROtf tT. v.. --• i.`-Cs4!; t{Iti.Di7.G- 7 r��r�//L
No.
7 a ula'o ty .4
AACIIITSCToR , Fliit } PNlOA•Nf TYPE
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DEMR_7r7:ON OF WOR= • •• 1
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ALTERATION
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REPAIR • DWOLITION .._ ••••,�+" �'�i•.'�r.•Ta'i� :jy .w
S ' N0. OR
PtComs
QT WA .2..... ROOT STORI[t
COYERINO
US[OFtTRUCTUR! COWERING •' ., : - r
• .. -a-w-..`••Jaw.. _ •.. I r • � -
1 N[R[tY ACKNOWL[DO9 THAT 1 111 =. `g•i• t"•"" I 11IONATI EAT71
_ PLICATION AND STAT! THAT THE NFORNATION tIV, j �+LT10Ni LOCATION -
CORRECT• -- g MATCRIALS
NIeoaOiR[! TO tbY FORf
17 O4 N �q MRA°'CTIDNti LIA7kT1 PR•aeTta a+'17td kTp "� ;•;
LA NO w7 wNTY RDINANCC4 AND STAT[ tR
W6 REOYLATINa tWt.DING CONETRUCnON. fid.BOLTS*' :-.• _:. -A
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