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HomeMy Public PortalAbout6016 PRIMROSE AVE_Building__ y.i .10RKER5,COMPENSATION DECLARATION j,here, effirilln per that I Dave .p ers'Come of consent to self ® P P L I C Qj � F P BUILDING PERM I insure, ora Ferlficate of Workers'Compensation Insurance, 9"'® ra or a cdrtifieVcopy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. L Company BUILDING [rtified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ( yy� OSy I Certified copy is filed with the county building inspec- BUILDING ` f tion department. ADDRESS �Q�[ I e � Date —�v[ Applicant r�CITY a ZIP :.LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' N 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 BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. OWNER N0. ;USE ZONE MAP I certify that in the performance of the work for which this NO. Y permit is issued, I shall not employ any person in any manner Yr �� SPECIAL 0 SS so as to become subject to the Workers Compensation Laws. ADDRECONDITIONS U Date Applicant CIN ZIP 99 NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCE ED BY P Y I ENGINEER NO• �� CONST., / ZONE MA Exemption, you should become subject to the Workers' Ig\/. IV/ Compensation provisions of the Labor Code, you must forth- ADDRESS N with comply with such provisions or this permit shall be . TEL. STATISTICAL CLASSIFICATION APT. C0/00. deemed revoked. I,CONTRACTOR NO. �� LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ,_0 1 NO. V63 2 (commencing with Section 7000)of Division 3 of the Business and L r LIC, SEWER MAP Professions Code,and my license is in full force and effect. CITY to CLASS-- BK PG. VALIDATION �10�y ""i' C°12-C Z SIR ISTORIES FAMILIES CONE HECK License Number ic.Class �{ o � ;VA:LUAT1:0NContractor - 1 ate DESCRIPTION OF WORK NEW ❑ADD ❑I am exempt under SecALTER ❑B.BP.C. for this reason ! dfiLi o9DE REPAIR ❑ Date: USE OF i MOL ;@3 9 6 2 A EXISTING BLDG. ICY(V_4— Signature APPLICANT TEL. FINAL rJ� # 0 0 0 0 0 1 OWNER-BUILDER DECLARATION PRINT) �(('�� a.�L / NO. Z3 DATE Z C� Qn I hereby affirm that I am exempt from the Contractor's License ADDRESS CJe D l� �"" 4 6'/ a PINA ( o - 6(150 Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT BY X 0 0060,5050 1:1I, as owner of the property, or my employees with ADDRESS ���S !'�R a, es" wages as their sole compensation,will do the work and 1,3 1 =8 6 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. a 1:5 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQESETBACK CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP . LIINEFR M 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 a' P.L. Lender's Name `�O'/f� LDMA Ref. # P.C. Fee$ Permit Fee J �J Lender's Address ``_0 Miliiiiii� r I certify that I have read this application and state that the Issuance Fee �l �/ LDMA P/C# x above information is correct. I agree to comply with.all County Investigation Fee ordinances and State laws relating to building construction, Total Fee V LDMA Perm. # and her authorize representatives of This County to enter iiiiii $ upon t e above-mentio ed property for inspection purposes. aif"C.V7 SEE REVERSE FOR EXPLANATORY LANGUAGE 0 ignatu of Applicant or Agent Date �y .;ARKERS%COMPEL�WION DECLARATION + {.h rAby §f cri thou I have a certificate of consent to self APPLICATION ®RBUILDING PERMIT cl insure, or a certificate of Workers?'Compensation Insurance, or a cerlified 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 (/ 6_ kd � d ❑ Certified copy is filed with the county building inspec- BUILING � � tion department. �J ADDRDESS Cl C7 ` Date / / L Applicant II L/i� '�- CITY �f7 �e /,r_7__y zip /7(` O LOCALITY cERTiFICAIE OF EXEMPTION FROM WORKERS' NO.OF SIZE OF LOT S�X /�4� NOW ON LOGS. NEARESCROSS ST. COMPENSATION INSURANCE (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK /AGE �J PARCEL A� TEL. NO. I certify that in the performance of the work for which this OWNER / CfC/� NO.lYrj � USE`M�Z1'ONE MAP / permit is issued, I shall not employ any person in any manner ADDRESS S� +� d7��/✓��f®�, �� k-� SPECIAL CONDITIONS v so as to become subject to the Workers'Compensation Laws. qq 8 CITY Z-1 TIC ZIP // 7.3✓ 6C Date Applicant ARCHITECT OR t TEL. NOTICE TO APPLICANT: If, after making this Certificate of �//1�-��/�4��L4� /, 6/ DISTRICT GROUP TYPE FIRE PROCE SED BY ri Exemption, you should become subject to the Workers' ENGINEER /l f/� —NO.��' �+ ' D" A 3 CONSTV Z(1(JEam Compensation provisions of the Labor Code, you must forth- ADDRESS � P6119/CT� lU( 'Jl `J� with comply with such provisions or this permit shall be �� f- TEL. dJ o STATISTICAL CLASSIFICATION APT. ONDO. deemed revoked. CONTRACTOR E t�v �� NO. T 7.3 r i �,e {�J LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. GAC DWELL. UNITS�` I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS JQ�� %� 7��tt tsN NO. (commencing with Section 7000)of Division 3 of the Business and r O j� LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY �i� /ter r CLASS BK./— PG. 6 VALIDATION SQ.FT. NO.OF 2 NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE KV IIS�II VALUATION Contractor Date DESCRIPTION OF WORK NEW X11 $ ❑ , I am exempt under Sec. /^J 726047726047ADD%/e �• rl ALTER ❑ � ' B.$P.C:for this reason 101,1114U REPAIR ❑ $ tied D 2) o a o o Date: USE OF DEMOL EXISTING BLDG. ❑ Signature APPLICANTPRINT) NO. ADDRESS /y�EAl TEL. i �� FINAL �/' I o 6 1 S V OWNER-BUILDER DECLARATION // oaff �) !�1t DAT — I hereby affirm that I am exempt from the Contractor's License x /_7 /t'/ �l�l{�/,�t7�lrt kA MC h1 7-,Ca Law for the following reason (Section 7031.5, Business and FI L Professions Code): PRESENT (J �, I �! `• 6 F-11,I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY ff .l -- the structure is not intended or offered for sale(Section - 7044, Business and Professions Code). MOVING TEL. KA I,as owner of the property, am exclusively contracting CONTRACTOR NO.Pahl �• �, with licensed contractors to construct the project (Sec- ADDRESS 1�" o o a ( j T_ tion 7044, Business and Professions Code). i $' CONSTRUCTION LENDING AGENCY REQUIRED SET BACK YARD HWY TOTAL SETBACK FROM PROP. LINE WIDTH O 2 1 1 — I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. S 11 (Sec. 3097, Civ. C.). SIDE 'o P.L. P o o Lender's Name d✓6/yt - LDMA Ref. N , i ( P.C.Fe Lender's Address e$ ! 5 ) / / I certify that I have read this application and state that the 4- 6 3 r[ 2_ Issuance Fee t� V LDMA P/C# L; above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee L7� s LDMA Perm.R Ll l I and hereby authorize representatives of this County to enter upon tA above-mentioned property for inspection purposes. ����, SEE REVERSE FOR EXPLANATORY LANGUAGE O Signature of Applicant or Agent / Dale r l ., '. , 4—R VjL64KERSl COMPENSATION DECLARATION PERMIT n 9•hereby affirm that I have a cdrtificote of consent to self P / ® ] insilre, or a certificate of Workers'Compensation Insurance, !9 �1 I� or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company L BUI D ❑ ING l d Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS O/ 0 4 p ❑ Certified copy is filed with the county building inspec- BUILDING / // �� ���; tion department. ADDRESS y-[yd//J p Date Applicant CITY /E � �� /T! ZIP O p LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' p NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT 'S� O S� NOW 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 MAP BOOK PAGE PARCEL OWNER TEL.�'I >�1' USE ZONE MAP I certify that in the performance of the work for which this SPE 0. permit is issued,I shall not employ any person in any manner ADDRESS 7'�6 ° �Jr�� Uf 3 SPECIAL V so as to become subject to the Workers'Corrfpensation Laws. CONDITIONS ' %/ CITY 4rL C7J�'J zip �/ �3 b Date Applicant. 7` �i � TE L. NOTIC TO APPLICANT: If, after making this Certificate of ENGINEER OR -=/���r NO.TJ �/� DISTRICT GROUP TYPE FIRE PRO SS BY Exemption, you should become subject to the Workers' /� 5j CONST. ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS / 4061,41147 /! e �'�� � � � fA LA with comply with such provisions or this permit shall be QG6,e�G &J,,A TEL. r�r y h STATISTICAL CLASSIFICATION APT. ONDO. deemed revoked. CONTRACTOR �� '.� NO. J �J i LICENSED CONTRACTORS DECLARATION //� /��1� J� LIC. CLASS NO. ���'' DWELL. UNI 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS y C'i !Y• 6�w/ NO. (commencing with Section 7000)of Division 3 of the Business and yyy LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY ,a� ✓�•a D pv 7e CLASS BK / PG /4'7 VALIDATION SQ. FT. 2 NO.OF NO..OF CHECK License Number Lic.Class SIZE �QJ STORIES FAMILIES ONE yy�� VALUATION Date: EXISTING BLDG.� Contractor Date DESCRIPTION OF WORK NEW �t $ ` �-�,�p/N� �>.� ADD ❑ :; ;938 1.9 A ❑I am exempt under Sec. ALTER ❑ 0 0 0 0 2) B.BP.C. for this reason '06'woz 16*f REPAIR E] $ USE OF DEMOL ElV tf ° 6 1 O I Q Signature APPLICANT ,�], _( /`] �f7/ 1 1 PRINT /lu 1`r '✓�'GJ�t NO. / tf FINAL :� 0 0 6 Q, ('j c� OWNER-BUILDER DECLARATION � DATE / I hereby affirm that I am exempt from the Contractor's License 7� A!� `p��®�f/A� �,/ /napl"tZ Law for the following reason (Section 7031.5, Business and ADDRESS FINKatz/ 1. 14-86 Professions Code): PRESENT Y 1 _1�_ ' F1 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 rr�� 7044, Business and Professions Code). MOVING TEL. jQI,as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- # © � ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM 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 Ps Lo. (Sec. 3097, Civ. C.). SIDE o 'o !i p ,p L �.� P.L. - ,L' fu' - .�- Q � p r5 = Lender's Name / -1,57 LDMA Ref. # r o t Q y,L o pt Q C P.C.Fee$ "(J Permit Fee 7 / a ° o 9 C J�S Lender's Address !1! / f} _,1 ` r I certify that I have read this application and state that the �" t"!*r�s Issuance Fee �(J V ILD P/C# Q G 1 =3 6 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee s LDMA Perm. # and hereby authorize representatives of this County to enter 5 upon the above-mentioned 13roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent p6te