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Home My Public Portal About9002 PENTLAND ST_Building__ WORKERS COMPENSATION DECLARATION YI hereby affirm thot'I have�a,certnc�atf of consent to self - t Insure or a certificate of Workers iCompensahon insurance • w+q-�,}AP,PLICATION- FOR� BUILDI�IG PERMIT 1 or a certified copy thereof (Secr3800 Lab C ), y:" c . l i �:, _ ��a✓.' ° .� Y COUNTY OF LOS ANGELES\ _ :,^ BUILDING AND SAFETY Policy No Company ~ ^ BULDING E'/y,- •9N ' Q FOR APPLICANT TO,FILL IN " ' r - ' Certified copy is hereb''lurmshed ADDRESS I " Candled copy is filed with the county budding mspec- BUILDING'(� R - ' pori department " u ADDRESS :\ 't LOCALITY {n`:1 ^p I P ` NEAREST e/�.t (Date tl Applicant d CITU. �� 9ZIP ,�\ CROSS ST !/�L CERTIFICATE OF+EXEMPTION FROM WORKERS NO OF BLDGS y _( ASSESSOR COMPENSATION INSURANCE ` SIZE OF LOT .1'i_ _ CMJ LOTS l h; MAP BOOK PAGE PARCEL , t(Thii section need not be completed if the permit Is for one USE ZONE MA ' c TRACT a BLOCK �r LOT NO' \ NO hundred dollars ($100)or less ) Z r 2 - ; 1( X,1"rF 1 \F\ TEL N �J� Q� J_ SPECIAL r If certdy thatrm the performance of the work for which this -:4 OWNER ♦ V t�10' CONDITIONS IS. l� 1; C DISTRICT GROUP TYPET r FIRE" PROCESSED BY O . permit a mued I ihall not employ any person in any manner rv,\ ` so as to b�ecome'subje I to the kern mp sa n Laws ADDRESS `0��+ v� ( � CONS ZONE U Date\\\Applicant ` ' • CITY,• ` ` ZIP \� STATISTICALFICATON APT CONDO O NOTICE TO APPLICANT-01 f"alien making t Certificate oft-_' y' ARCHITECT OR\ �y] `. Exemption, you should'become sub lett to the Workers' ENGINEER NO CLASS NO DWELL UNITS_ 1 Compensation provisions of ThetLobor Cade you must forth-Tr��1 � SEWER MAP - N with comply with such provisions or this permit shall be TEL _ t Z deemed revoked i L• CONTRACTOR L_�, vJ�. �l NO RS DECLARATION 0' `` BK PG VALIDATION �- LICENSED CON TRACTO I hereby affirm that I am licensed under provisions of Chapter 9 rj ; ADDRESS \; v •,._L�_ANO C\"•� S VALUA ION (commencing with Section 7000)of Division 3 of the Business and ' LIC , Professions Code and my license is in full force and effect j:, CITY _ Cis CLASS'\ ,.. s f PON. , - ' _ SOFT 'F7 NO OF NO OF CHKK License Number Lic ClassSIZE L/ STORIES FAMILIES ONE ' + Contractor Dote DESCRIPTION OF WORK NEW E] ' I am exempt under Sac `� �� \� ADD ® q ( ' B 8P C for this reason ♦ ALTER E] _ DA EFINAL / �aJ¢ u t 6 7 1 A r , ! REPAIR- E]t USE OF ^ Date 6 EXISTING BLDG �ty'OL NAL ❑ Y Signature FAPPLICANT TEL - OWNER-BUILDER DECLARATION - PRIN7 NO I hereby affirm that I am exempt from the Contractor s License +` 2 • • 6 a b 3 Law for the following reason (Section 7031 5 Busmess and ADDRESS - Professions Code) PRESENT e • • 6 a 6 s'x, - , as owner of the property or my employees anBUILDING - i ADDRESS I 1 1 0,-83 wages their sole compensation,will o the work andd u the structure is not intended or offered for sale(Section + LOCALITY 7044, Buamess and Professions Code) MOVING TEL - T...rN GI - t I as owner of the property, am exclusively contracting❑ CONTRACTOR NO t with licensed contractors to construct the project (Sec- I - _ II�� •�� !,t 4 tion 7044 Business and Professions Code) ADDRESS GIS •Lvr LO REQUIRED TOTAL SETBACK FROM EXIST 4 , // ry T CONSTRUCTION LENDING AGENCY SET BACK YARD TOTAL PROP'LI WIDTH' ' ' ",y - C¢-rj (e r D' a ' I hereby affirm that Iis a construction agency for FRONT - - the performance of the work for which thisis permit M mit is issued P L (Sec3097-Gv C ) SIDE • �'- �' b b Lender s Name - S Lender s Address PC Fee S Permit Fee 14 r �s certify that I'hove read this application and state that the z -e Z, Iuuanc,Fee I. above above infomnotwn is correct I agree to comply with all County" Invese n Fee• - y /' _ -ordinances and State jaws relating to budding construction Total Fee :(t7 1 TG 3 L7 and hereby authorize representatives of this County to enter n. a ve-me ned arty for impaction purposes • - •� I + I .+^'= `` t - { SEE REVERSE FOR EXPLANATORY'LANGUAGE �v 'J r i L^ Signature Applimni or Agent we WORKERS COMPENSATION DECLARATION • ) ' ' , 1 tf,� APPLICATION FOR' BUILDING PERMIT' TILJII ,r` II heresy aNfYm that have'a certrfimte of consent to self f isure `or o certificate oaiie'a'ers Compensation Insurance + ,or a certified copy thereof (Sec 3800 'Lab C ) ' " ° , . j COUNTY OF LOS ANGELES BUILDING°AND SAFETY Policy N • - - Company - ` Cl`embed copycis hereby furnished FOR APPLICANT TO FILL IN BUDDING Oa� ADDRESS �n' 'Certified'copy is filed with the county budding inspec BUILDING 'hon department ADDRESS (Date r -Applicant ,! It '" CITY , �� ZIP , LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS - OF BLDGS NEAREST '•' ', f COMPENSATION INSURANCE ' SIZE OF LOT "`d NOW ON LOT CROSS,ST (This section need not be completed If the permil`stfor one - ASSESSOR 3° hundred dollars ($100)or less )� . TRACT BLOCK LOT LOT NO MAP BOOK PAGE PARCEL F. s� IST s TIDO a6 ds� USE ZONE MAP " , OWNER _ I(certify that in the performance of,the work for which this T r .j NO 7. I permit I4s tied I shall not employ p on in any er r: ADDRESS t �y SPECIALIO • r so as to'become subject to the Wo s' m ash i ss CONDITIONS r Date �' s APPbcd'nt ' CITY ZIP , \ + ' " s 8 'NOT( TO LICANT If ofte making this Certificate of ENGINEER ARCHITECT OR w y .r'TEj TEL DISTRICT GROUP OPT FIRE • SSED•By y 0, Exemption you ishould become subject to the Worker w, /�1� R f..) Compensation provisions of the Labor Code you must forth ADDRESS', �_ c{/ V J �Ld with comply with such provisions'or this permit shall be _ r - 'd deemed revoked TEL STATISTICAL CLASSIFICATION APT CONDO 0 L, a. CONTRACTOR NO -v oz LICENSED CONTRACTORS DECLARATION v _ _ LIC CLASS NO DWELL UNITS ° I hereby affirm that,I am`licensed under provisions of Chapter 9 ADDRESS a NO ± (c`ommencing with Section 7000)of Division 3 of the Business and LIC SEWER P _ Professions'Code, and my license is in full force and effect CITY' 4' CLASS A 9K VALIDATION s ` S0 FT NO OF NO aF CHECK - Ltce, Number Lic Class d SIZE STORIES FAMILIES' _" ONE r r- _ I r VALUATION " s . . + f-- DESCRIPTION OF WORK i NEW Contractor Date _ ❑ $ O am exempt under Sec j - 72? - ADD ` T T. + ALTER , ` B&P C•for this reason ` - REPAIR - r - USE OF., Data E%ISTING BLDG ., DEMOL ` Signature ' - 'y - A—(PRINT)) 'OS NOW�1 FINAL �Z�J TEL OWNER BUILDER DECLARATION r ,/� _ DATE L hereby offirm,ihot am exempt from the Contractor a License `' ' ADDRESSr,Yr '�`� FIN Law for the,following reason (Section 7031 5 Business and Prof''asiom Code) ' -+ r - , By _ . . �pF • 0,01 • + r �• r I e)'e py y3�y� I as owner of the property or my employees wnh we structure their sole compensation, will f o the work and J} J j r \_ t 0 9 1 66 88 a the structure a not intended or offered for,sole(Section LOCALITY' 1 5 � I N.� , V Iv y 1 _ 7044, Business and Professions Code). '- •+ MOVING L ' ,f t TEL - ' y 1 I OS owner of the property am the contracting C TRACTOR. 1 t .Y NO \ _ „ with, contractor to construct the piojeci(Sec- - 'r • ' ' ''+L • 10 .. -1F �. + bon 7044 Business and Professions Code) + ADDRESS ""'' CONSTRUCTION LENDING AGENCY' ' RE �"'' SETBACK.) YARD HWY� TOTALP SETBACK VLINEr I hereby affirm that there iso construction lending agency for FRONT the performance of the work for which this Permit is issued P L j`.1 ,� ,'• ., (Sec 3097, Cry C ) r SIDE .. .' ' P L 'Lend S s Names -- _ ' . Y ' LDMA Ref Lender s Address Tx PC Fee$ Perm. 'I certify that I have read this application and state that the lns once Fee (DMA P/C above information is correct I ogres to comply with Oil County, Invesiigotion Fee ` $ ordinances and State jaws relating to budding construction, _ ''; Total Fee LDMA Perm R R and b ouch ae rep a ntahvas of this Countyto enter op t e, vs- entia d rop"forinspaCJ,O /put »mss; Y _ ^,r SEN REVERSE FOR EXPLANATORY LANGUAGE /� Si e f Apel nt . Agent, bote I I C -- WORKERS COMPENSATION DECLARATION 04 �. i, f l ' he„lby offinn that lehave a certificate of consent to self %~ APPLICATION. FOR BUILDING PERMIT '.7l�fll \^ insure or a certificate of Workers Compensation Insurance or a certified cop' thereof (Sec 38DO Lab C ) - e - - COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING911Lz , DDSS Certified copy a fled with the county building mspec BURDING ` ARE qtollion department ^ t r + ADDRESS Date Applicant - CITY • G'R ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERSs 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 - TRACT BLOCK LOT NO 5 s ASSESSOR t1— 1 hundred dollars ($100)or less I - MAP BOOK PAGE PARCEL . TEL / USE ONE' MAF I certify that in the performance of the work for which this • OWNER NO Q7 �qI NO 4 permit is issued I shall notem ploy y p n in an annex AOORESS •1 u1 Jl SPECIAL so as to bet m subject to tho n m n Lows 2— HrZdJ At 0 U NOTI Appbcont ARCHITECT OR ZIP TEL , T - 0 NO71C T APPLICANT If off r mak g ,hu erlrfi< rk of ENGINEER NO DISTRICT/ G/R/pUP TYPE FIRE SSEDitBV O Exem do you should become su jecl to the Workers' r�Jy K CnNST / Z�E U Compensation provisions of the Labor Code you must forth- ADDRESS ' J s(/O Y J with comply with such provisions or this permit shall be TEL deemed revoked CONTRACTOR O NO STATISTICAL CLASSIFICATION APT IN cn '0114 s ' Z LICENSED CONTRACTORS DECLARATION _ LIC CLASS NO DWELL UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO (commencing with Section 7000)of Division 3 of the&rimes,and _ LIC SEWER MAP Professions Code and my license is in full force and effectCITY CLASS - IO I - , VALIDATN • 'i ++ C s SO FT NO OF / NO OF CHECK, BK PG License Number tic Class 1 SIZE STORIES FAMILIES ONE ' + /� VA ATI N DESCRIPTION OF WORK iJ NEW D Contractor Date ADD 90. / , J I cm exempt under Sec II + . ALTER B&P C for this rection REPAIR $ - - • - Date - D5E OF 2 E DEMO E%ISTING'SLDG C•7 Signalurer ° - - APPLICANT nn,, TEL - FINAL r _ OWNER-BUILDER DECLARATION +^ PRINT RV S NO DATE •� 7 974a.1 A I hereby affirm that I am exempt from the Contractor s LicenseADDREu O_•s Law for the following reason (Section 7031 5 Business and CJ�� FIN # • • •'•i•I� , Profys BUILDING s Cade) -- - - `- y - - By •lsY�7y`� . I as owner of the property or my employees with ADDRESS I • 1 21!1.88 wagei as then sole compensation well do the work and - ^ � q' F: the structure is not intended or offered for sale(Section LOCALITY f y t r i f' t'f •t•l 2 4,8'8'9 7044 Business and Professions Code) r MOVING r + - TEL i - •� 't \� O ,T 6.-87 cs owner of the property am exclusively contracting CONTRACTOR - NO J 1 1 L with licensed contractors to construct the project (Sec + ADDRESS - - - - , _ •- tion 7044 Business and Professions Code) v , CONSTRUCTION LENDING AGENCY - SET BACK YARD HWY TOTAL LINEWIDTHm - - t�'; tr. hereby affirm that there a construction lending agency for i FRONT + ` 'the performance of the work for which this Permit is issued - M P l t (Sec 3097 Gv C ) SIDE i �.• PL Lender ti Name .- PC Fee$ Perms Fee LDMA Re/ N •-”: 1 Lender s Address' '+ , 1 cernf that 1 have rood this application and state that the 7t - ; Y PP - Issuance Fee _ _ LDMA,P{C N 1 t above information is coved I agree to comply with all County Investigation Fee $ ordinances and State laws relating to building construction, Total Fee R and hereby Guth nze repreaentahves of thU County to enter IDMA Perm N _ t upon a ve enhon roperty for mapechon rposes - ^ • a $EE QVQSE FON EXPLANATORY LANGUAGE r �� of t or Apent - 6oto , it