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HomeMy Public PortalAbout6412 OAK AVE_Building__ Ir WOIrKERS'COMPENSATION QECLARAAON yiakure bor ce of cote of that I W kersrtCo[[mpensat on Insurance, `fJ L� aT i N FOR BUILDING P E RM I T or a certified copy the ec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING ANDS FETY P❑olicyNo. any BUILDING r. : ,.. ._;... Certified is y hereby furnished. FOR APPLIC T T FILL ADDRESS Certified copy is filed with the county building inspec- BUILDING ,�1� tion department. ADDRESS (� / v LOCALITY /�" NEAREST Date Applicant CITY Ci ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLD S. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK GE PARCEL (This section need not be completed if the permit is for one USEPNEPhundred dollars($100)or less.) TRACT BLOCK LOT NO. NO.TE /�►— q� SPECIAL 9 I certify that in the performance of the work for which this OWNER N Jr/�� CONDITIONS permit is issued,I shall not employ any person in any manner DISTRICT GR P TYPE FIRE PR SSED BY O ADDRESS34 /,(� CONST./ ZE so as to become subject to the Workers'Compensation Laws. / V 1( Ipf/ U CITY (� ZIP OD(p `/ O Date Applicant STATISTICAL CLASSIIFJCATION DO. u NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR T L. I Exemption, you should become subject to the Workers' ENGINEER ^ / 0 .p N CLASS NO. DWELL. UNITS IL Compensation provisions of the Labor Code, you must forth- ADDRESS k ascv0�� JOoGV SEWER MAP with comply with such provisions or this permit shall be deemed revoked. TEL' �� ` BK. PG, VALIDATION CONTRACTOR v N G LICENSED CONTRACTORS DECLARATION LIC. _ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATIO (commencing with Section 7000)of Division 3 of the Business and LIC. TNEW Professions Code, and my license is in full force and effect. CITY G`4/ CLASS SQ. FT. NO.OF NO.OF ECK i License Numb4r Z1i.Class SIZE STORIES FAMILIES NE Contractor a Date '— DESCRIPTION OF WORK D ADD Iam exempt under Sec. ❑ ALTER ❑ FINAL G B.&P.C. for this reason - y e e REPAIR ❑ DATE Date: USE OFDEMOL FINAL 1 EXISTING BLDG. ❑ illy Signature APPLICANT TEL. / 33 OWNER-BUILDER DECLARATION PRINT pr�e�J NO 70M- I hereby affirm that I am exempt from the Contractor's License ADDRESS * ©��p/ — &Mke— Law for the following reason (Section 7031.5, Business and Professions Code): PR ENT El1,I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY 7 Q Q 9 A the structure is not intended or offered for sole(Section 7044, Business and Professions Code). C.7 MOVING TEL. # 0 0 0 0 0 1 I,as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- A ADDRESS a 1 4 3.63 tion 7044, Business and Professions Code). 0 0 143636 7ETBACK TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY LYARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for 5,12 .-8 7 the performance of the work for which this permit is issued tSec. 3097, Civ. C.).Lender's Name 3 P.C. Fee$ Permit Fee Lender's Address /p rI certify that I have read this application and state that the Issuance Fee �(/ above information is correct. I a e to comply with all County Investigation Fee ordinances and State laws rel g to building construction, Total Fee and hereby authorize re rese fives of this County to enter { upon tt� b -m do ed p perty for inspection p rposes. ( SEE REVERSE FOR EXPLANATORY LANGUAGE Si oture of Applicant or Agent Date ®s =RKERS'COMPENSATION DECLAMATION I he/re af'cer Pica I hove r certificate of consent to self P P L I CAT I fel FORBUILDING PERMIT � 1 instke,'o•a'�erfificate of Workers'Compensation Insurance,orM\certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ y FOR APPLICANT TO FILL IN BUILDING � Certified copy is hereby furnished. t; ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDINGk Imo, tion department. ADDRESS a-2 �A f Date Applicant CITY ZIP (J LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' O.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR -hundred dollars ($100)or less.) TRACT m BLOCK LOT NO. / MAP BOOK PAGE PARCEL YD 6E �- NO. USE Z NE MAP OWNER 3 1 certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in y anner 7� Y,�/�Q �� SPECIALIL so as to become subject to the War m en. Ti Laws. ADDRESS CONDITIONS Date Applica CITY ZIP CC ` NOTICE TO APPLICANT: If, r making this Certificate of ; ARCHITE OR TEL. DISTRICT G OUP TYPE FIRE PRO E ED BY ENGINEER NO. �/ CONST. / ZONE Exemption, you should be ome subject to the Workers' 5_ (�j( (.// Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be ��r�tTEL. STATISTICAL CLASSIFICATION A . deemed revoked. CONTRACTOR t _ eI- VINO. LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS . r NO. (commencing with Section 7000)of Division 3 of the Business and / / LIC SEWER MAP Professions Code, and my license is in full force and effect. " CITY 44:4a Y'jMLf,J1��C/ CLASS BK � PG�3 VALIDATION SQ.FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK 1 S NEW ADD ❑.. $ polo, 96424A ❑I am exempt under Sec. 11FOa:P W7 a a- e ALTER $ # 0 0 0 0 0 B.&P.C, for this reason ° REPAIR ) o 0 6 Q 5 0 Date: USE OF EXISTING BLDG. U&4 DEMOL 0 0 0 6 Q 5 0 53 Signature :APPLICANT y TEL. FINAL OWNER BUILDER DECLARATION (PRINT) J,S^ Lo���/` 0.7i ?03 DATE �� Q 1,2 8 e 7 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS d� SAX =� �/O ^��ke pIN Professions Code): PRESENT By l ❑ BUILDING I, as owner of the property, or my employees with ADDRESS w ges as their sole compensation,will do the work and e structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. 00 owner of the property,am exclusively contracting CONTRACTOR NO. with licensed no to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FRO 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. (Sec. 3097, Civ. C.). SIDE i P.L. i Lender's Name LPerm. Lender's Address P.C.Fee$ Permit Fee t 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 ws luting to building construction, Total Fee i and hereby authorize rep entatives of this County to enter I upo e- a ion property for inspection purposes. ' �7 SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Appi i6nf or Agent Date ( OO y RKERS'CO NSATION DECLARATION � PKICATION �lllL®I PERMIT �.1 hereby (ffirm-YRat I �hcive a certificate of consent to self `�rnsdt[s3, o a 2ertificate of or rs'Compensation Insurance, oro certified/copy Cher 3800, Lam`) COUNTY OF LOS ANGELES BUILDING AND SAFETY Po icy o.` ' ny ❑ Certified c y is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING J tion department. ADDRESS /���� ^7�- �� I / �7/� Date Applicant CITY e � 8// ZIP / 7u(J LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' `ff PNO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT OW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR -hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL p� TEL. USE ZONE MAP I certify that in the performance of the work for which this OWNER Y7F' / NO. NO. permit is issued, I shall not employ any person in any manner 8 -Z "( SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS 6� VVV��` CONDITIONS 40Q 99 U ' - ~ - Date Applicant CITY ZIP ARCHIT OR 7EL.•a,j Q £ NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NOa�r+ S� V DISTRICT GROUP TYPE FIRE SSED 8Y Exemption, you should become subject to the WorkersG J CONST. ZONE Compensation provisions of the Labor Code, you must forth- ADDRESSLet— 45.:5OkGI �'� with comply with such provisions or this permit shall be L. STATISTICAL CLASSIFICATION AFL CONDO. N deemed revoked. CONTRACTOR NO. )� g LICENSED CONTRACTORS DECLARATIONtIC. CLASS NO.QL__DWELL. UNITS .I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Di NO. ffVZSEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code,and my license is in full force and effect. CITY I-A CLASS VAL��pp��►T�� � SQ.FT..yy..�� pp NO.OF NO.OF CHECK BK' PGA,- —moi-J'�A License Number Lic.Class SIZE d.4�J�STORIES FAMILIES ONE I� / VALUATION # 0 0 0 0 0 1 Contractor Date DESCRIPTION OF WORK LL I NEW $ //� D d a Oetft Gp SC= ADD ! / pool. I ° 8 5 7,2 5 ❑I am exempt under Sec. L,^s ALTER ❑;. $ 5 7 2 J5 5: B.BP.C. for this reason �]u REPAIR ❑:.. Date: USE OF:EXISTING BLDG. e DEMOL ❑OF 1 1223-86 Signature APPLICANT TEL FINA OWNER-BUILDER DECLARATION PRINT S NO f r? DATE I hereby affirm that I am exempt from the Contractor's License }� Law for the following reason (Section 7031.5, Business and ADDRESS PO. PlD�.7 �'Tt6C� bQe? El FIN Professions Code): PRE ENT BY El 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 L 7 A 7044, Business and Professions Code). MOVING TEL. ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. ; ° o 0 0 3 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). I o 72 a6 7 REQUIRED TOTAL SETBACK F CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT o r, '� E> J the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE G 5'"8 6 c P.L.. Lender's Name // LDMA Ref. # P.C.Fee$ � UPermit Fee 5 kl o Lender's Address _ rI certify that I have read this application and state that the Issuance Fee LDMA P/C# ( above information is correct. I agree to comply with all County . Investigation Fee ordinances and State.laws relating to building construction, Total Fee �O 7e LDMA perm, # and hereby authorize re resenfatives of this County to enter upon al ve-m ntio d property for inspection urposes. M, r rz SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of App icant or Agent Date 0 t