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Home My Public Portal About9813 RICHMOND WAY_Building__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR BUILDING PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker.'s'Compensation Insurance, or,a certified cop here f kSec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY USF$G Policy o. ompany 11 ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRIESS I.J 3 Certified copy is filed with the county building inspec- BUILDING _# tion department. ADDRESS i / 3 IM p t' Date 4-23-89 Appl ica CITY ZIP 91780 LOCALITY NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION F W CES ' SIZE OF.LOT 87000 NOW ON LOT 0 CROSS Sr. �- �y COMPENSATION INSL�2ANCE ASSESSOR (This section need not be completed if the permit'is for one TRACT 43136 BLOCK LOT O. 3 MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) Westco Land Inc. No' 286-363 USE ZONE F=N ! //��OWNER � '7'I certify that in the performance of the work for which this v „ PECIAL >permit is issued, I shalI not employ any person in any manner +?ADDRESS 1425 Me1anie Ln. ONDITIONS a. so as to become subject to the Workers'Compensation Laws. r; OO. cliY Arcadia zip 91006 Date Applicant ARCHITECT OR TEL. ix NOTICE TO APPLICANT: If, offer makingthis Certificate' Same DISTRICT GROUP TYPE FIRE PR SSEDBY O ENGINEER NO. f CONST. �NE l- Exemption, you should become subject to the Workers' VV Compensation provisions of the Labor Code, you must forth- t ADDRESS 3• dq P-3 3- nw with comply with such provisions. or this permit shall be TEL. STATISTICAL CLASSIFICATION / APT. CONDO. Z deemed revoked. CONTRACTOR NO. _ LICENSED CONTRACTORS DECLARATION �' LIC-265864 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 LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY CLASS B BK PG. VALIDATION �! SQ. FT. NO.OF NO.OF CHECK License Numbe 7 Lic/AClass �'?SIZE 2 1 6 0 STORIES 2 FAMILIES 1 ONE I9 tr VALUATION a Coniractor�� ►�'��"' mate x DESCRIPTION OF WORK NEW Wit' - ADD ❑ :. 7 :�__ 'Ridtil attached 2 _ El am exempt under Sec. esenaaacecar ALTER ❑ ,� _'_ BAP.C. for this reason : Garage, REPAIR ❑ $ USE OF AA Date: EXISTING BLDG.S i n g l e F a m i l 3 Family R e s i DEMOL ❑ Si nature APPLICANT TEL. g h ' (PRINT).George W i e g a n d NO.2 8 6-3 6 3 6 FINAL OWNER I hereby affirm that I am exempt from the Contractor's License =ADDRESS 1425 M e l a n i e Lane Arcaa d i a Law for the following reason (Section 7031.5, Business and FINAL. Professions Code): PRESENT By •BUILDING ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole-compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section ® VI 7044, Business and Professions Code.) tMOVING TEL. 1,1 ❑ 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.) n -'REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SEYARD HWY T BACK PROP. LINE WIDTH t/ 1 I hereby affirm that there is a construction lending agency for FRONT the performance.cif the•work for which this permit is issued . > P.L. g 9 s� (Sec. 3097, Civ. C:). - SIDE . Lender's Name B B H Mortgage P.L: _J d 90� 96c3 Ref. dP bb' 8383 Wilshire Beverly Hill` P.C. Fee Permit Fee "e , Lender's Address a I certify I have read this application and state that the e,3- 1. Issuance Fee o t-•+ LDMA P/C# '- above information is correct.I agree to comply with all County Investigate , ordinances and State laws relating to building construction, Total Fee a LDMA P and hereby authorize representatives of this County to enter r.. upon the bove-mention ro a =inspeti n'purp se . cc tz O o f SEE REVERSE FOR EXPLANATORY LANGUAGE 9°Op.' °.,L •O rJ Signal of A icon r A t 01 CJI APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDI1Jq ADDRESS or a certificate of Workers'Compensation Insurance,or a certified f C, JAI0,"r'0 copy thereof(Sec.3800,Lab.C.) zip Company S 1, er LOCALITY o Policy NO SIZE OF LOT NO.OF BLDGS.NOW ON LOT Certified copy is hereby furnished. NEAREST GROSS ST ❑ Certified copy is filed with the coon uilding inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. ASSESSOR MMMM 88 OK PAGE PARCEL Date plica ;-T f d� zq� G' SPECIAL CONDITIONS /� AI / CERTIFICATE OF EXEMPTION FROM RKERS' OWNER OO TEL NO COMPENSATION INSURANCE O o--q WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRES C-4 DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars($100)or less.) CITY / ZIP I certify that in the performance of the work for which this permit L �� is issued, I shall not employ any person in any manner so as to ' become subject to the Workers'Compensation Laws. ARCHITECT OR GINE... TEL NO STATISTICAL CLAS�SIFJCATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become Subject to the Workers CONTRACTOR ' TEL NO. 1, SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith WO FRONT comply with such provisions or this permit shall be deemed revoked. ADDRES LIC NO. P L l � 4 a LICENSED CONTRACTORS DECLARATION clrY� uc��s Z FIDE I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ. T SIZE NO.OF STORIES NO. F FAMILIES tY Professions Code,and my license is in full force an effect. �6 7 NEW � BK PG C License Number ,7t0 Lo Lic.Class DESCRIPTION OFRWQ K - • A ADD ❑ VALUATION , LL Contractor 13 fLD�ri(SDate-]�/�— ��a �Q `c O Cau ALTER 11 $ W• 0 0 LL ❑ I am exempt under Sec. G X 6 8 J<<D t REPAIR ❑ $ BAP.C.for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLD URM 1:1Signature - APP CANT(PRINT) n TEL NO FFINAL Perm# 23 _ ❑ 1, as owner of the property, or my employees with wages as GAv dLJ Z AC( I.v their sole compensation, will do the work and the structure is ADDRESS / F ;3a3 r�e a[I not intended or offered for sale (Section 7044, Business and ti�GL� DATE aProfessions Code.) D00. WALL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ I, as owner of the property, am exclusively contracting 44, AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? BY A licensed contractors to construct the project (Section 7044, � ACCT.a Business and Professions Code.) .YES❑ No �y WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING sa U3 110.711 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR a_ ITEMS GUIDELINES. ,_,/ I hereby affirm that there is a construction lending agency for YES 11 No TOTAL :16 1 a 20 the performance Of the work for which this permit is issued(Sec. IHAVE READ TH HAZARDOUS MATERIALS INFOR UIDE AND THE SCAOMD PERMITTING r t/ 3097,CIV.C.) CHECKLIST I UND ND MY REQUIREMEN ER THE LOS ANGELES COUNTY CODE, CHECK 161.20 Lender's Name MATTITLE 2,C REPORTING SECTIONSOR OBTAI 10 A PRM T FROM THE SCAOMD.CONCERNING HAZARDOUS � CHANGE .00 Lender's Address ER OR AGENT 3 I certify that I have read this application and state under penalty o P.C.FEE PERMIT FEE ! p of perjury that the above information is correct.I agree to comply p CIGOO-0001 7 1c/96 with all county ordinances and Sta ws relating to building' U construction ffbov"e-m authoriz resentatives of this County ISSUANCE FEE 7-&- 7—t'(0--? 5 ?45� 1 All 8:03 nt on the do property for inspection purposes. 7—t'(0 INVESTIGATION FEE TOTAL FEE / • 0 lura a A9P't:,u a ApMI D-W SEE REVERSE FOR EXPLANATORY LANGUAGE