The URL can be used to link to this page

Home My Public Portal About6268 RENO AVE_Building__ ,moi .,• -- - ,,, WORKERS'COMPENSATION DECLARATION c I hereby affirro that I have a certificate of consent to self o I nsure, dr a certificate of Workers'Compensation Insurance, A P P L I CAT°I O N FBUILDING PERMIT or d certified copy thereof(Sec. 3800, Lab. C.) COUNTY.OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUDDING r °ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS Date Applicant CITY J !JC ZIP % � LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST 1 COMPENSATION INSURANCE SIZE OF LOT Ox �� NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars($100)or less.) ` OWNER IC�,� L-• �yI NO. US NJ [EPPENNIAL P I certify that in the performance of thew for which this // /�permit is Issued, I shall not employ any on in any manner ADDRESS 64 (��V CODITIONS Q so as to beco a subject to the Work ompens Ion Laws. Q CITY � // '�/r ZIP U Date Appltco ARCHITECT OR ov TEL. NOTICE TO APPLICANT: If, after maks this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' �`/�(( /; CONST ZONE V IL Compensation provisions of the Labor Code, you must forth- ADDRESS V O E( Lr l with comply with such provisions or this permit shall be � TEL. STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked. CONTRACTOR ieO f� NO. 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 Business and LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK VALIDATION SQ.FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION DESCRIPTION OF WORK NEW r �f Contractor Date' I.. ADD s J I am exempt under Sec. n�"�� r® ALTER �l: 9 7 7.6 A 6.8P.C. for this reason `�� " REPAIR [J1 ' $ # a.a o.00 � Date: USE OF EXISTING BLDG. DEMOL ❑;. Signature APPLICANT - TELtS FINAL PRINT �—1 l'� NO :( a a 4 Q 5 0 OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS% -t7 ��'�� /G� FINAL o o o 4 0 5 0 Law for the following reason (Section 7031.5, Business and � 5 Professions Code): PRE5ENT BUILDING By 0603:`''88 I, as owner of the property, or my employees with ADDRESS v wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section rADDRE Y 7044, Business and Professions Code). I G TEL. ' j,as owner of the property,am exclusively contracting CTOR NO. with licensed contractors to construct the project (Sec- S tion 7044, Business and Professions Code). I IRED TOTAL SETBACK r CONSTRUCTION LENDING AGENCY ACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for T the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name h LDMA Ref. N c ' Lender's Address e$ PermitFee I certify that I have read thisapplication and state that the Issuance Fee / U �/ LDMA P/C# above information is correct. I agree to comply with all County ation Fee <� ordinances and State laws relating to building construction, Total Fee , J LDMA Perm. N R and hereby authorize representatives of this County to enter $ upon the above-mentioned property for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE m Signature of Applicant or Agent Date r WORKERS'COMPENSATION DECLARATION R to sel insure.oraafcertif cairmrte-of Wprke s'Compensation I have a certificate ofconsent Insuran of A P P L I CAT I N F®R BUILDING PERMIT .� tr a cert!,Ned copy 1 hereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company go ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS C/ Certified copy is filed with the county building inspec- BUILDING El t5Z6g ,t��7O v� tion department. ADDRESS �'r 4 /,F (� Date Applicant CITY /4ir�i &- 4/ ZIP q1 7 0 LOCALITY / CERTIFICATE OF EXEMPTION FROM WORKERS' O X//� NO.OF BLDGS. z NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This'section need not be completed if the permit is for oneASSESSOR hundred dollars ($100)or.less.) TRACT BLOCK LOT'NO. MAP BOOK PAGE PARCEL TEL. USEFE MAPCr- OWNER g/�/p L / N NO.Z � a] I certify that'in the performance of the work for which this // ,p NO. permit is issued, I shall not employ any person in any manner ADDRESS C� Z�� a/1 CJ4� I SPECIAL so as to become subject to the Workers'Compensation Laws. !_ 1 CONDITIONS O CITY76 b U Date Applicant 0; NOTICE TO APPLICANT: If, after making'this'Certificate of ARCHITECT OR TEL. DISTRICT GR UP TYPE FIRE PROC SED BY O Exemption, you should become subject to the Workers' ENGINEER -� CONST'./ Z E U Compensation provisions of the Labor Code, you must forth- ADDRESS t D� K W with comply with such provisions or this permit shall be deemed revoked. V TEL. ":STATISTICAL CLAS 1CATION APT. DO. cn CONTRACTOR NO. ! Z LICENSED CONTRACTORS DECLARATION LIC: CLASS NO. ( DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER P (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 I I A BK VALIDATION SQ. FT. NO.OF NO.OF ` CHECK License Number Lic.Class SIZE �� STORIES FAMILIES / ONE • VALUATION DESCRIPTION OF WORK NEW C] i Contractor Date $ J(/C/ 'r ADD. REPAIR ,g. I am exempt under-Sec. /V C� l ALTER ❑ BAP.C. for this reason �qT yOo l�J ' $ ❑' Date: USE OF DEMOL ❑ .. EXISTING BLDG, g 7 9 1,3 A Signature APPLICANT ,,p ` TEL. FINAL ,O OWNER-BUILDER DECLARATION PRINT T��,,`y�� G. /rYI NO, g�'� DATE # e 0..q 0 0 1� I hereby offirm'that I am exempt from the Contractor's License ADDRESS ��"'/ g G V FIN (,o o '�$ (]0 Law for the following reason (Section 7031.5, Business and G 0 0 0 7 8 0 0 53 Professions Code): E BY ❑ BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work cind LOCALITY -09. 1 4"87 the structure Is not Intended or offered for sale(Section 7044, Business and Professions Code). I MOVING TEL. ❑ I, 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 5ETBA 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 P.L. - Lender's Name �f (( LDMA Ref. # u P.C.Fee$ Permit Fee /' [J Lender's Address I certify that I have read this application and state that the Issuance Fee �(l LDMA P/C# above information's correct. I agree to comply with all County Investigation Fee ? ordinances and at laws relating to building construction, Total Fee LDMA Perm. # and her a orize representatives of this County to enter S upon the a e-mentions roperty for inspectiq�7 c o /� , SEE REVERSE FOR EXPLANATORY LANGUAGE �gnature pplicant or Agent