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Home My Public Portal About5755 RIO HONDO AVE_Building__ WORKERS'COMPENSATiO,N DECLARATION iiTisureboraffir- that .a'c�rtif cajof Workers'tCompensat o--iricate of n Insurancent to e, APPLICATION FOR BUILDING P E RM I T or a 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 BUILDIDRESS NG s ' ADc Certified copy is filed with the county building inspec-, BUILDING ter—•- __/ tion department. ADDRESS Q Q Q � LOCALITY Cr+ Vi Date Applicant CITY ZIP NEAREST CROSS ST. rwa 14 CERTIFICATE OF EXEMPTION FROM WORKERS' i NO.OF BLDG%. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT A 00 NOW ON LOT '7, MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one TRACT Q BLOCK LOT NO. r� USE ZONE MAP Z -- hundred dollars($100)or less.) TEL. SPECIAL > I certify that in the performance of the work for which this OWNER � i4L NO. 9-Y CONDITIONS 9L permit is issued, I shall not employ any person in any manner, DISTRICT GROUP TYPE FIRE PR ESSED BY 0 so as to become su jec to the Wor ers'Comp e sation Laws. ADDRESS Q ,W Av CONST. ZONE J �- 8 �� e 0 Datepplicant CITY ['E ZIP STATISTICAL CLASSIFICATIONCONDO. NOTICE O AP LICA T: If, afte aking this Certificate of ARCHITECT OR TEL. LU Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL.UNITS 9L Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be deemed revoked. TEL. BK VALIDATION CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VAL AT ON (commencing with Section 7000)of Division 3 of the Business and 1 LIC. 0 9 b 7 A Professions Code,and my license is in full force and effect. CITY CLASS $ SQ. FT.q NO.OF NO.OF A CHECK ® # 0 0 0 0 0 License Number Lic.Class SIZE ` STORIES FAMILIES IV ONE NEW $ Contractor Date � DESCRIPTION OF WOR ❑ . ! C ADD I am exempt under Sec. 0?' JJ y L9 '^ �� ALTER ❑ FINADATE , �J��Q B.BP.C. for this reason W DATEGD G L/ REPAIR ❑�� I a - 49,88 USE OF FI Date' EXISTING BLDG. FDEMOL ❑ Signature APPLICANT y� ,L TEL., 0 0 0 49.88'0 g PRINT �J A 6, M9 A L NO.2S& OWNER-BUILDER DECLARATION �I G I G26-84 I hereby affirm that I am exempt from the Contractor's License gDDRESs iY �� L�¢ �G Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT I, as owner of the property, or my employees wiBUILDING th ADDRESS wages as their sole compensation,will do the work and 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. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT Fe the performance of the work for which this permit is issued P.L. tSec. 3097, Civ. C.). SIDE m P.L. Lender's Name 39, _3 o P.C.Fee Permit Fee e Lender's Address 1 certify that I have read this application and state that the Issuance Fee t above information is correct. I agree to comply with all County Investigation Fee g ordinances and State laws relating to building construction, Total Fee and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. n SEE REVERSE FOR EXPLANATORY LANGUAGE ®s Signature of Applicant or Agent Date WORKERS/COMPENSATION DECdu4RATION1, I hereby affirm that 1 96v a cer tificate-of consent•%tr's?A-•�,-.r •.— '`h �•�,��`� ®� ©M � B L O N PERNT T insure, or a certificate of Workers'Compensation Insurdnce, C�, lll LLJJ or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING ANDSAFETY i-ri Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDDING SS �11:✓fr�f - Certified copy is filed with the county building inspec- BUILDING i tion department. ADDRESS Ileu f ` LOCALITY /+ t NEAREST Date Applicant tl ZIP ` CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' O.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT 7 OW ON LOT MAP BOOK PAGE PARCEL (This section need not.be completed if the permit is for one USE ZONE MAP hundred dollars($100)or less.) TRACT 7 BLOCK LOT NO. NO. / Q TEL. SPECIAL } I certify that in the performance of the work for which this OWNER �. 7 ds NO. !1� I CONDITIONS IL DISTRICT .GROUP TYPE FIRE PROCESSED BY O permit is issued, I shall not employ any person in any manner ADDRESS _ CONST. ZONE so as to become sub' ct to the Workers'Compensation Laws. ``� CIN ' s ZIP N 'P Date?J�� Applican ` STATISTICAL CLASSIFICATION APT. CONDO. NOTICE TO APPLICANT: If, of Aing this Certifica a of ARCHITECT OR TEL. , ENGINEER NO. CLASS NO. DWELL. UNITS Exemption, you should become subject to the Workers' � Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this-permit shall be n TEL. "rte � deemed revoked. CONTRACTOR(�! / NO. BK. '? PG. VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VA77N (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 $ SQ. FT. NO.OF NO.OF ✓ CHECK License Number Lic.Class SIZE STORIES ONE FAMILIES ONE ONE POP % DESCRIPTION OF WORK �D NEW ❑ $ Contractor Date ADD _ ❑ I am exempt under Sec. I - ALTER C] FINAL B.&P.C. for this reasonE] DATE REPAIR USE O Date: F PIN EXISTING BLDG. DEMOL ❑ Signature g APPLICANT PRINT TO.EL. [t1_ ?„) OWNER-BUILDER DECLARATION N I hereby affirm that I am exempt from the Contractor's License ! '�a-r t V� t�t 1Q /' Law for the following reason (Section 7031.5, Business and i ADDRESS✓7' _ t�` li Prq essions Code): PRESENT BUILDING I, as owner of the property, or my employees with I ADDRESS wages asiheir sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code)., MOVING TEL. E] I,as owner m CONTRACTOR NO. of the property,•aexclusively contracting v 1,0 with licensed contractors to construct the project (Sec- ADDRESS 'tion 7044, Business and Professions Code). ;: 0 a 0 o a REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH r 1 hereby affirm that there is a construction,lending agency for FRONT D 2 0 1 d 1. " the performance of the work for which this permit is issued P.L.' _ JSec. 3097,.Cly. C.). SIDE., 0 - I. 35 :_ v Lender's-Name - I o7.3 'P.C.Fee$' Permit Lender's Address � �, 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 laws relating to building construction, Total Fee d and hereby authorize representatives of-this County to enter :.:. upon the above-mentioned property for inspection purposes. I Af SEE REVERSE FOR EXPLANATORY LANGUAGE ie ISignaturpplicant or Agent � I ®s