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Home My Public Portal About5760 OAK AVE_Building__ -•,WORKERS COMPENSATION DECLARATION ••;I hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT insure or a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company BUILDING 1:1Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS u``7�Pv ❑ Certified copy is filed with the county building inspec R� �LG tion deportmentADDRESS p� Date Applicant airy ZIP pv LOCALITY 1 0' NO OF BLDGS NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT CROSS T COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACE BLOCK LOT NO MAP BOOK PAGE PARCEL hundred dollars($100)or less) TEL OWNER NO USE ZONE MAP I certify that in the performance of the work for which this SPECIAL permit is issued I shall not employ an person in any manner ADDRESS CONDITIONS so as to b m subject to the Wore Compen tion OV CITY 4WA4e ZIP d Date Apphcont ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE BY O NOTICE O APPLICANT If after king this Certificate of ENGINEER NO �g CONST ZONE t- Exemption you should beco subject to the Workers ,.�j 0 Compensation provisions of the Labor Code you must forth ADDRESS // with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO deemed revoked CONTRACTOR NO LICENSED CONTRACTORS DECLARATION UC 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 FT NO OF NO OF CLASS CHECK PG VALIDATION License Number Lic Class SIZE I STORIES FAMILIES ONE VALUATION DESCRIPTION OF WORK NEW p� Contractor Date ADD ❑ $ ❑I am exempt under Sec PooALTER B&P C for this reason - REPAI $ pia USE OF EXISTING BLDG DEMOL Signature APPLICANT T) NO FINAL OWNER BUILDER DECLARATION DAT I hereby affirm that I am exempt from the Contractor s License ASR Law for the following reason (Section 7031 5 Business and FIN f &Anions Code) dl► I as owner of the property or my employees with ADDR� jh r— avages as their sole compensation will do the work and �L r$ the structure is not intended or offered for sale(Section LOCALITY ► ;; 17 40 7044 Business and Professions Code) MOVING TEL ❑ I as owner of the property am exclusively contracting CONTRACTOR NO i 1TOS with licensed contractors to construct the project(Sec ADDRESS , TQTAL 40.To tion 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY SET IRED YARD HWY TOTAL �I F EXIST C0 ISI,90 1 hereby affirm that there is a construction lending agency for FRONT performance of the work for which this permit is issued PL 4 +r •00 (Sec 3097 Civ C) SIDE " PL Lender s NameO Q LDMA Raf Lender's Address PC Fee Permit Fee i frK_ 1 AM a 12 Ts I certify that I have read this application and state that the Issuance Fee ZO LDMA P/C 0 0 above information is correct I agree to comp) with all CountyInvestigation Fee C ie ate laws relating to building construction Total Fes , v LDMA Perm 0 rob a representatives of this County to enter ntio opertYfor inspection p s SEE REVERSE POR EXPLANATORY LANGUAGE Applicant or Agent Date � COMPENSATION DECLARATION *� insure bar a cert+f+ate of WorkersrtCompensat�nsensurance APPLICATION FOR BUILDING PERMIT or a certified copy thereof(Sec 3800 La COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Co CNINE ertified copy reby furnished FOR APPLICANT TO FILL IN BUILDING D G Cert+f+ opy is filed with the county building mspec BUILDING apartment ADDRESS .lpp�� /y� r ate Applicant CITY ysiL G ZIP l D LOCALITY �rL LG r rq CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST Q v COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT ROSS ST /�/t (This section need not be completed if the permit is for one TRACT BLOCK LOT NO ASSESSOR hundred dollars($100)or leas ) MAP BOOK PAGE PARCEL TEL USE NE I MAP I certify that in the performance of the work for which this OWNER AA NO _ NO _ permit is iaa ed I shall not employ an ersci in any mann V O SPECIAL so as to be oIm subject to the Work C pen + ws ADDRESS p� CONDITIONS uas CITY sow ZIP 1�p� Dots Applicant r NOTICE O APPLICANT If after makin is a if+cate of ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY O Exemption you should become subject to Workers NGINEER NO g CONST ZONE V Compensation provisions of the Labor Code you must forth W with comply with such provisions or this permit shall be ADDRESS � L s at deemed revoked CONTRACTOR STATISTICAL CLASSIFI TION IAPT Z LICENSED CONTRACTORS DECLARATION ��ssw,�, UC 33�9i CLASS NO DWELL UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS I / l NO 7 (commencing with Section 7000)of Division 3 of the Business and ` LICII SEWER MAP Professions Code and my license is in full force and effect CITY (. CLASS(✓� // 3�0 9 f, A BK PG VALIDATION License Numb rWer Clara ` ` SQ SIZE� STORIES tFAOM1221 NO OF CONE AW fVALVA, N Contractorta DESC AIOt�OF�WQU:RWK 'j PA� NEW a I am exempt � ^"w M u 10 ADD Poll"1 ALTER B 8P C for thEJOLis reason br' 7 REPAIR = Date XISTING B i Signature APPLICANT T LL FINAL OWNER BUILDER DECLARATION PRINT KMfNOpA �_ I hereby affirm that I am exempt from the Contractor s License $O 5 a 6 A Law for the following reason (Section 7031 5 Bus+ nd ADDRESS FINAL �q Professions Code) By # e e e e e 1 BUILDING El I as owner of the property y employees with ADDRESS i ) e e96,75 wages as their sole compen on will do the work and the structure is not integ0a or offered for sale(Section LOCALITY , + e * 967553 7044 Business and essions Code) MOVING TEL 13 1as owner off property am exclusively contracting CONTRACTOR NO 0902-88 9 O 2 8 8 with hcense ontractors to construct the project (Sec gDDRE55 tion 7044 us+ness and Professions Code) „ RE�UIRED TOTAL ` CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH I hereb irm that there is a construction agency for FRONT the armance of the work for which this permit +s issued P L ( 3097 Ctv C ) SIDE PL Lender s Name , Lender s Address -16 wMA Ref #P C Fee S Permit Fee I certify that I have read this application and state that the Issuance Fee L S—D EA P/C# o above information is carred I agree to comply with all County Investigation Fee // t1� 8 ordinances an tate laws relating to dmg construction Total Fee 4 -J LDMA Perm 0 N and ereby t nze eprese of this CoQ unty o enter u the a men ro rty for insped+on r r(e/s m0/ 5EE REVERSE FOR EXPLANATORY LANGUAGE Slgnatu Appl ant or Agent Dite WORKERS COMPENSATION DECLARATION F I hereby affirm that 1 have a certificate of consent to self insure or a certificate of Workers Compenstion Insurance or WLICATION FOR BUILDING PERMIT a certified copy thereof(Sec 3800 Lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company Certified co is hereby furnished ADDRESS 0 K BUILDING ❑ copy y FOR APPLICANT TO FILL IN ❑ Certified copy is filed with the county building inspec BUILDING tion department ADDRESS LOCALITY ` ' NEAREST Dam Applican _ CITY ZIP CROSS ST S CERTIFICATE OF EXEMPTION FROM WORKERSO OF BLDGS ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit �s for one 0 USE ZONE MAP O hundred dollars($100)or less ) TRACT BLOCK LOT NO / NO O TEL SPECIAL IL I certify that m the performance of the work for which this OWNER NO CONDITIONS permit is issued I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY U so as to become subject to the Workers Compensation Laws ADDRESS e� CONST ZONE 0 CITY Date Applicant ARC CT OR ZIP T STATISTICAL CLASSIFICATION APT CONDO 11 W NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO — CLASS NO DWELL UNITS d Exemption you should become subject to the Workers #A Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP Z with comply with such provisions or this permit shall be �q deemed revoked CONTRACTO nr.X Tr C O f NO BK PG / VALIDATION LICENSED CONTRACTORS DECLARATION LIC 1 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 "� $ ®p SQ FT NO OF NO OF / CHECK Dense Number Lic Class-4!1SIZE STORIES FAMILIES / ONE f� J NEW $ .Contractor pate�/ '�+� DESCRIPTION OF WORK ❑ I 12 am exempt from the licensing requirements as I am a - ADD licensed architect or a registered professional engineer ALTER ❑ FINAL acting in my professional capacity (Section 7051 REPAIR ❑ DATE Business and Professions Code) USE OF EXISTING BLDG DEMOL ❑ FINAL By Lic or Reg No Date APPLICANT TEL OWNER BUILDER DECLARATION (PRINT) N y I hereby affirm that I am exempt from the Contractor s License O� Law for the following reason (Section 7031 5 Business and ADDRESS U p i// rProfessions Code) /O 7 ❑ BUILDING I as owner of the property or my employees with ADDRESS wages as their sole compensation will do the work and 19-5 68.3 A the structure is not intended or offered for sale(Section LOCALITY 7044 Business and Professions Code) MOVING TEL # • • • • • 1 as owner of the property am exclusively contracting CONTRACTOR NO with licensed contractors to construct the project (Sec ADDRESS 2 - 25750 tion 7044 Business and Professions Code) REQUIREDTOTAL SETBACK FROM EXIST • • 2 5 7 S O 5CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT 0 8 17-82 7_$2 the performance of the work for which this permit is issued P L (Sec 3097 Civ C ) SIDE PL Lender s Name r0 ' Lender s Address P C Fee$ i� Permit Fee �QT� 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 jaws relating to building construction Total Fe and hereby authorize representatives of this County to enter u4pont above mentioned prop rfy for inspection purposes P� i 11 purposes a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or AgdKt Dote Os