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Home My Public Portal About5756 RIO HONDO AVE_Building__ WORKERS' COMPENSATION DECLARATION 4 sure or certificate that I have r certificate of consent to self P P L I CAT I FOR BUILDING PERMIT insure; or a certificpte of Workers' Compensation Insurance, ,- or-arc-e�rtiffjed copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY P6Lccj NOJ. 2 '+�S Company � BUILDING E f Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ,s�7�6 IV, 1810 /(a{ /✓ !/'e Certified copy is filed with the c my building inspec- [BDING S�s6 - �1 Dtion department. r/ ?(i/� ZIP 9/�Q p LOCALITY / Ci 1'E- Date Applicant �� NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' T -90 / (a NOW ON LOT CROSS ST. Gv0 f{COMPENSATION INSURANCE ASSESSOR(This section need not be completed if the permit is for one BLOCK LOT NO. MABOOK PAGE PARCEL hundred dollars ($100)or less.) USE ZONE MAP ,Ck S7'e N1� NO. �S 3/�O I certify that in the performance of the work for which this h NO.SPECIAL permit is issued, I shall not employ any person in any manner ADDRe p p &Vo0-31 CONDITIONS n' so as to become subject to the Workers'Compensation Laws. O CITY-1-4e✓Y/ I-K ZIP Date Applicant [AR HITECT O TEL. DISTRICT GROUP TYPE FIRE RO ESSED O NOTICE TO APPLICANT: If, after making this Certificate of NEER NO. CONS . E U Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- RESS S'D 9 a- with comply with such provisions or this permit shall be //�� / o/ TEL. STATISTICAL C IF TION o CONDO. N deemed revoked. TRACTOR(.�� A 4JJ*A! NO.33rA4 j z LICENSED CONTRACTORS DECLARATION - �ps LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 RESSl NO.�SZk'J-S' LIC. SEWER MAP (commencing with Section 7000)of Division 3 of the Business /� and Professions Code,and my license is in full force and effect. '71l�E77'�f40" / CLASS A CHECBK PGVALIDATION License Number / Sze-S�Lic. Class 19 �C/p 9 STORIIEES r AMILLIIES ONEK 9 VALUATION Contractor -.rJ Date ® RIPTION OF WORK f ,� �-� � NEW \ t ADD❑I am exempt under Sec. �� /CE 7l ! ALTERB.&P.C. for this reasonOFREPAIR ❑ $Date' ING BLDG. DEMOL ❑ Signature APPLICANT TEL, ,,, / g OWNER-BUILDER DECLARATION (PRINT) (�, AA1 NO•�� irl7 y DA EFINAL I hereby off irm that I am exempt from the Contractor's License ADDRESS 7 ! /�e� �� Law for the following reason (Section 7031.5, Business and v FINAL7//�yv ; Professions Code): PRESENT By BU LDING ❑ I, as owner of the property, or my employees with ADDRESS ACCT.Ir wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 3307 106.13 7044, Business and Professions Code.) MOVING TEL. ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. It 1 ITEMS E 1TT�1� 5 T with licensed contractors to construct the project (Sec- ADDRESS TOTAL 106. 13 tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM MST. CHECK �yt CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH iVVo 13 1 hereby affirm that there is a construction lending agency for FRONT CHANGE .011 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name b600-101001 9/ 6/89 Lender's Address 8 P.C. Fee$ Permit Fee f LDMA Ref. # Jc' (0 3 5-510 1 AM 8-'26 1 certify that I have read this application and state that the Issuance Fee i LDMA P/C# above information is correct. I agree to comply with all County 41 Investigation Fee ordinances and State laws relating to building construction, Total Fee o 13 LDMA Perm. # c and hereby authoriz repre ntatIves of this County to enter uPon above- tinned roperty for inspec on purposes. o 14 LY—_S7-_' SEE REVERSE FOR EXPLANATORY LANGUAGE Signa of pp scant or Agent Date WORKERS' COMPENSATION DECLARATION S^ I heLegy affirm that I have a certificate of consent to self APPLICATION FOR BUILDING P E RM I T i_insure, or a certificate of Workers'Compensation Insurance, or a�cVrfifje��yQhereof (Sec. 3800, L� �� COUNTY OF LOS ANGELES BUILDING AND SAFETY `Polt�c o. j ? Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ' AOd .11v ❑ Certified copy is filed with the county building inspec- BUILDING tion de artment. � � 4 ,,�Q,t/ CITY G�� ZIP g�7t�l? LOCALITY Date Applicant NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT o 0 ,L NOW ON LOT J CROSS ST. C,vOa2N� COMPENSATION INSURANCE ASSESSOR ((This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL, OWNER s G NOa�� 9Q USE ZONE MAP I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in any manner ADDRESS 5"7S"(p41—,400 �y�v .01 SPECIAL a CONDITIONS so as to become subject to the Workers'Compensation Laws. ) 0 CITY �� /e zip �! �G Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONS ZONE Exemption, you should become subject to the Workers' 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. CONDO. Z deemed revoked. CONTRACTOR NO. — LICENSED CONTRACTORS DECLARATION tyLIC. CLASS NO. DWELL UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force a effect. CITY CLASS BK PG VALIDATION � ySQ. FT NO. OF NO.OF CHECK License Number ��J,v Lic. Class SIZE �O STORIES IFAMILIES ONE ? VALUATION Contracto Date 2-2 DESCRIPTION OF WORK NEW ❑ $ ❑I am exempt under Sec.� + B ADD ❑ pool ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL Signature APPLICANT TEL. FINAL CJ OWNER-BUILDER DECLARATION (PRINT) NO. DATE l o I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL 1 Professions Code): PRESENT By ACC b ❑ I, as owner of the ro erf or m employees with BUILDING R44To4 P P Y� YADDRESS wages as their sole compensation,will do the work and 3307 60.50 the structure is not intended or offered for sale(Section [AD CALITY 7044, Business and Professions Code.) VING TEL 1 Ing ❑ 1,as owner of the property,am exclusively contracting NTRACTOR NO. with licensed contractors to construct the project (Sec- DRESS TOTAL 60.50 tion 7044, Business and Professions Code.) CHECK 60.5 i EQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY ET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for RONT the performance of the work for which this permit is issued •L• (Sec. 3097, Civ. C.).- IDE .L. M-CM1 9J 6/x°9 Lenders Name . Fee$ Permit Fee LDMA Ref. # 11 Atdo+�j'7 Lenders Address A i 1 certify that I have read this application and state that the Issuance Fee ®a J LDMA P/C# above information is correct. I agree to comply with all County Investigation.Fee ordinances and State laws relating to building construction, Total Fee 60Z LDMA Perm. # and he y authorize r prase fives Of this County to enter upo a above- ed p party for inspects purpose r� SEE REVERSE FOR EXPLANATORY LANGUAGE Sign re of Ap Iicant or Agent Date