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HomeMy Public PortalAbout6374 OAK AVE_Building__ ORKERS'COMPENS°ATION DECLARATION hereby affirm that I have a certificate of consent to self APPLICATION F O I� BUILDING PERMIT insure, or a certificate of Workers'Compenstion Insurance,or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company _ /� /t J� ❑ Certified copy is hereby furni hed. 7`7q OR APPLICANT TO FILL INBUILDING6J 7 IV " ADDRESS �( (%G"/I ❑ Certified copy is filed with the county building inspec- Y BUILD tion department. ADDR . LOCALITY .. NEAREST Date / Applicant CITY ZIP CROSS ST. n ,Q—!/t CERTIFICATE OF EXEMPTIO FROM WORKERS' NO.OF BLDGS. ' ASSESSOR COMPENSATION INSURANCE SIZE ONOW ON LOT MAPBOOK PAGE PARCEL (Thissection.need not be completed if the permit is for one USE ZONE MAPhundred dollars($100)or less.) TRACBLOCK LOT NO. NO. L. SPECIAL I certify that in the performance of the work for which this 1OWNER NO % SS CONDITIONS O DISTRICT GROUP TYPE FIRE PROCESSED BY permit is issued, I shall not employ any person in any manner ADDRESS � � � CONST. ZONE U so as to become subject to the Workers'Compensation Laws. ,� p- �iG� Date Applicant CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO. U NOTICE TO APPLICANT: If, after making this Certificate of ARCHITE ENGINEER OR !1' TEL. LU Exemption, you should become subject to the Workers' �Qf CLASS NO. DWELL. UNITS Compensation provisions of the Labor Code, you must forth- to ADDRESS,7 r f SEWER MAP with comply with such provisions or this permit shall be �r�f _ ,� � TEL. deemed revoked. CONTRACTOR C.�/" NO. BK. PG, s VALIDATION LICENSED CONTRACTORS DECLARATION n'B LIC. �`/ p I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS J�+' .tA6 N� 7�OoZ VALUAj(ON (commencing with Section 7000)of Division 3 of the Business and LIC. D 670 Professions Code, and my license is in full force and effect. CITY a CLASS $ q�r / Se-fT + INO).OF NO.OF CHECK License Numbet�T ,D Lic.ClassQ/ ��� - t+ RIES FAMILIES ONE Contracto r Date �r -� I NEW ❑ $ ESC PTI OF WORK ❑ I am exempt from the licensing requirements as I am a ° ADD ❑ licensed architect or a registered professional engineer ° ALTER E] FINAL r (' x. t acting in my professional capacity (Section 7051, DATE REPAIR Business and Professions Code). USE OF V EXISTING BLDG. DEMOL EJFIFINAL c c Lic.or Reg.No. Date APPLICANT TEL. By OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and t ADDRESS Professions Code): PRESENT ❑ BUILDING 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 7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. I v with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). ADDRESS REQUIRED TOTAL SETBACK FROM EXIST. 0 0 0 0 0 ) CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH :. I hereby affirm that there is a construction lending agency for FRONT r• the performance of the wo/rrk1,for which this permit is issued P L (Sec. 3097, Civ. C.). f�V SIDE P.L. - Lender's Name '• o t i _ I o' 1 P.C. Fee$ Permit Fee Lender's Address ' 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 o ordinances and State laws relating to building construction, ou and hereby authorize r resentatives of this County to enter Total Fee ww upon the abov a one pro erty f inspection purposes. _ „ r� SEE REVERSE FOR EXPLANATORY LANGUAGE o Signature ofIicant or AgeAt Date ®s e . . .. SCC F *ORKERWCOMFENSATION DECLARATION T" hereby affirm that I have a certificate of consent to self APPLICATION F®RBUILDING PERMIT tsure,or a certificate of Workers'Compenstion Insurance,or certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY olicy No. 142'�Ctf­ompany r.11BUILDING 7 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ,3 �-1 "I Certified copy is filed with the county building inspec- BUILDING _ J tion department. ADDRESS 2 f LOCALITY NEAREST ate Applicant CITY IP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' nn NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT O Pyr NOW ON LOT 02! MAP BOOK PAGE PARCEL 'his section need not be completed if the permit is for one USE ZONE MAP C,C`� undred dollars($100)or less.) TRACT �j BLOCK LOT NO. NO 9, OWNER TEL. P� SPECIAL 11 �O certify that in the performance of the work for which this CONDITIONS O DISTRICTADDRESS GROUP TYPE FIRE PRO SSED BY ermit is issued, I shall not employ any person in any manner CONST. ZONE ` U as to become subject to the Workers'Compensation Laws. i �j� 3• C7� 1730 ate Applicant "CITYTi� ZIP / 70(/ STATISTICAL CLASSIFICATIONAPT. CONDO. V OTICE TO APPLICANT: If, after making this Certificate ofARCHITECT O TEL. (emption, you should become subject to the Workers' ENGINEER NO. 3 CLASS NO. DWELL. UNITS ompensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP � ,ith comply with such provisions or this permit shall be TEL eemed revoked. CONTRACTOR NO. D BK. L PG, '3 VALIDATION LICENSED CONTRACTORS DECLARATION LIC hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N4,42226 VALUATION :ommencing with Section 7000)of Division 3 of the Business and _ LIC. r� -ofessions Code, and my license is in full force and effect. CITY CLASS $ SQ. FT. NO.OF NO.OF CHECK cense Number ( � T Lic.Class SIZE 16 STORIES FAMILIES f ONE /�/Joe)a ontractor .�.�� �.-CrA,K--Date In ^(' DESCRIPTION OF WORK NEW $ ��/ ] I am exempt from the licensing requirements as I am a 4.0 jig 4 ADD licensed architect or a registered professional engineer ALTER ❑ FINAL acting in my professional capacity (Section 7051, REPAIR E] DATE G� Business and Professions Code). ; USE. DEMOL Fl AL , EXISTING BLDG. ❑ 4� c.or Reg.No. Date APPLICANT TEL. By OWNER-BUILDER DECLARATION (PRINT) NO. hereby affirm that I am exempt from the Contractor's License iw for the following reason (Section 7031.5, Business and ADDRESS 46-2 3 10fessions Code): PRESENT BUILDING ���ppl/rr' 9 I, as owner of the property, or my employees with ADDRESS X42 2 d wages as their sole compensation,will do the work and / the structure is not intended or offered for sale(Section LOCALITY 7 7044, Business and Professions Code). MOVING TEL. o ] I, as owner of the property, am exclusively contracting CONTRACTOR NO. C. , with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH hereby affirm that there is a construction lending agency for FRONT to performance of the work for which this permit is issued P L iec. 3097, Civ. C.) ( SIDE P.L. :nder's Named '' Q� , 'nder's Address P.0 Fee$ a ZY�j '2 0 Permit Fe6"Zli eSQ V/ i� certify that I have read this application and state that the J�O� 00 7. oove information is correct. I agree to comply with all Count Issuance Fee V 9 g P Y g Y Investigation Feea /y'�� •dinances and State laws relating to building construction, Total ee d id hereby authorize representatives of this County to enter Son the abov mentioned pr r tns ection purposes. ti `.Gi✓� �es����:F�/fY SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dote es WORKERS'�COMPENgATION DECLARATION APPLICATION FOm WILDING PERMIT I hereby affirm that I have a certificate of consent to self insure,or a certificate of Workers'Compenstion Insurance;or . a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING / ' , ©� f/ Certified copy is hereby furni hed. � FOR APPLICANT TO FILL IN " Certified copy is filed with the county building inspec- BUILDING ADDRESS C] !�l // tion department. ADDRESS . LOCALITY //5G• /� 0 NEAREST Date Applicant CITY ZIP CROSS ST. CERTIFICATE OF EXEMPTIOW FROM 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 USE ZONE MAP d hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO. d J L. ��// ' SPECIAL p. I certify that in the performance of the work for which this OWNERa4et�lO f(p• 55 CONDITIONS 0 /' DISTRICT GROUP TYPE FIRE PROCESSED BY U permit is issued, I shall not employ any person in any manner ADDRESS (�J CONST. ZONE so as to become subject to the Workers'Compensation Laws. / Il: ` CITY ZIP Date Applicant STATISTICAL CLASSIFICATION APT. ICONDO.NOTICE TO APPLICANT: If, after making this Certificate of ARCHITE OR - !1 TEL. I � Exemption, you should become subject to the Workers' ENGINEER CLASS NO. DWELL. UNITS N Compensation provisions of the Labor Code, you must forth- ADDRESS % SEWER MAP with comply with such provisions or this permit shall be — deemed revoked. TEL. BK. PG, d VALIDATION CONTRACTOR NO. O LICENSED CONTRACTORS DECLARATION ��yy ��®®� LIC. ~/ I hereby affirm that I am licensed under'provisions of Chapter 9 ADDRESS 56 f'7+'�DVII-4 N� 74 a-f VALUAT ON p (commencing with Section 7000)of Division 3 of the Business and V LIC a D Professions Code, and my license is in full force and effect. `CITY n CLASS $ /� C� NO).OF NO.OF CHECK License Numbet C1 '96 'a^r Lic.Class �� RIES FAMILIES ONE �/(99� $ Contracto r Date tK� ESC PTIOt�TOF;WORK NEW ❑❑ I - I am exempt from the licensing requirements as I am a v ADD licensed architect or a registered professional engineer a ALTER ❑ FINAL acting in my professional capacity (Section 7051, 1plREPAIR DATE "`' —( Business and Professions Code). y USE OF FINAL _ EXISTING BLDG. DEMOL ❑ By Lic.or Reg.No. Date APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) NO. - I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and v ADDRESS Professions Code): PRESENT BUILDING 1,'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 7044, Business and Professions Code). MOVING TEL. TRACTOR NO I, as owner of the property, am exclusively contracting CON . ` .I 53 1 A with licensed contractors to construct the project (Sec- ADDRESS G tion 7044, Business and Professions Code). ft o a o o a 1 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 2 a a 6 1,0 0 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). / �M�`� SIDE o o a L 1 ( 4 P.L. Lender's Name �o 1 0. 1 3-8 1 i P.C. Fee$ Permit Fee Lender's Address I certif that I have read this application and state that the y PP Issuance Fee above information is correct. I agree to comply with all County Investigation Fee m ordinances and State laws relatingto building construction, v g Total Fee j and hereby authorize re resentatives of this County to enter upon the alb a one pro erty f inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature ofIicant orAg t Date es