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Home My Public Portal About6453 TRELAWNEY AVE_Building__ WORKER$ COMPENSATION DECLARATION • 1 surekYra cert fica Fhove r certificate of consent to raself APPLICATION FOR BUILDING PERMIT insure or o cenrficate of Workeri Compensation Insurance a.a certiflad c8py thereof (Sec 3800 Lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING ADDRESS M Certified copy a fled with the county budding impec BUILDING k Ck hon deportment ADDRESS E V Date Applicant CITY ZIP LOCALITY f 1 CERTIFICATE OF EXEMPTION FROM WORKERS' 60 i X 14'3 „,aNBL—NDDGS FEARESS SIZE OF LOT T V N COMPENSATION INSURANCE (This section need not be completed if the permit is for one ..� -rte' ASSESSOR hundred dollars ($100)or less ) TRACT BLOCK LOT NO MAP BOOT( PAGE PARCEL TEL .''''II T!YE, I certify that m the performance of the work for which this OWNER C. NO'I`i S� � Cd d permit is issued I shall not employ any person in any manner / COwRIONS O so as to become subject to the Workers Compensation Laws V Date Applicant CITY ZIP 9Z2FQ O NOTICE TO APPLICANT If after making this Certificate of ARCHITECT RC��R O ' 4-f NO DISTRICT GROUP TYPE FIRE ID BY F Exemption you should become subject to the Worker !� OCNST'/ Z3 sUL Compensation provisions of the Labor Code you must forth- ADDRESS f J Y with comply with such provisions or this permit shall be TEL .•ef` STATISTICAL CLASSIFI TION APT C NDO deemed revoked CONTRACTOR No �$O LICENSED CONTRACTORS DECLARATION LIC CLASS NO 2 DWELL UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO (commencing with Section 7ODD)of Divivon 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect CITY CLASS BK FG VALIDATION 1 SO R NO OF NO dF License Number Lc Clou SIZE STORIES ' FAMILIES ONE vuuAnoN Contractor Dote DESCRIPTION OF WORK NEW ADD FitFit am exempt under Sec t*Ttf ec. ALTER , I B 8P C for this reason OF REPAIR $ 'Y 2l V�1 U c) 31 6 7 7 A Dote 115E EXISTING BLDG DEN'OL # • • • • 2 3 Signature ��/i i/ ^i APPLICANT TEL FINAL 1 . 19286 l? r 9- 016N ER BUILDER D LARATION PRINT NO DA 1 hereby off irm that 1 am exempt from the Contractor s License Law for the following reason (Section 7031 5, Business and ADDRESS FINA • • 1 9 2 8 6 3 Pro essions Code)I, as owner of the BY o BUILDING 0 2 13-85 property, or my employees with ADDRESS wage as their sole compensation,will do the work and Pilo structure is not Intended or offered for sole(Section LOCALITY 70", Business and Professions Code) MOVING TEL F1I as owner of the property am exclusively contracting CONTRACTOR NO with licensed contractors to construct the project (Sec- twn 7044 Business and Professions Code) ADDRESS #2 It S1 Q 8 CONSTRUCTION LENDING AGENCY REOD SET�p,CK YARD HWY TOTALPROP LINE WIDTH 1 • 1431 1 1 hereby affirm that there is a construction lending agency for FRONT • • 1 4 3 1 1 '6 the performance of the work for which this permit is issued P L i Q Q 1 9-85 (Sec 3097 Civ C ) SIDE R PL J21860A Len cler s Nome TDMA Ref 1 # • • • • • 1 8 25- lender's Address PC Fea f / Permit Fee L 1 . 40575 I certify thot I have rood this application and state that the 7 Issuance Fee 0 n LDMA P/C 0 i above information u correct I agree to comply with all County Invetpatwn Fee > i J • • 4 0 S 7 5 5 ordinances and State lows relating to budding construction Total Fee (� J CDMA Perm 0 0 6. 17-85 and hereby authorizer esentatives of this County to enter n the abo m int property for inspection pu s r - SEE ff11ERSi FOR EXPLANATORY LANGUAGE Signaiun s of Applicant or Agent Dote _ APPLICATION FOR BUILDING PERMIT _ COUNTY OF LOS ANGELES BUILDI G AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL I BR�or+a I hereby athrm that I have a certificate of consent to saff Insure 6({ErjT 4 or a certificate o( Workers Compensation Insurance or a certified YC�QWYIt L copy thereof (Sec 3900 Lab C) c azy zWw J 7D 7 L Poky NO Coup" SIZE OF T NO OF BLOCS,NOW ON LOT ❑ Certified copy a hereby furnished L NEAREST CAM Sir ❑ Certified copy Is filed with the county building inspection TRACT BLOCK LOT NO department I USE ZONE MAP NO Dae Applicant ASSESSOR MAP PAGE (A PARCEL f A pyp eE5B SPECIAL CONDITIONS CEffnFICATE OF EXEMPTION FROM WORKERS' LI'TXIIEV C, JTE/ cj J(P$� YES NO COMPENSATION INSURANCE /�rrtr:t'RyFC � .' WITHIN 1bb0 Fr OF SCHOOLS (The section head not be completed if the permit is for ore hundred b1,J -r/c jai JNC ATFL � dsrRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars($100) or less) A 1 certify that m the performance of the work for which this permit C ZIP Is lamed I shall not employ any person in arty manner w as to AR OR ENGINEERTEL NO become subject t0 file NlTrkere Cortpensefim Laws owl-0— STATISTICAL CLASSIFICATION APT CONDO Date Applicant AGGRESS CLASS NO 4R DWELL UNITS NOTCE TO APPLICANT N after making the Certificate of REQUIRED TOTAL SETBACK FRCM EXIST Exerrlpten you should become alubtect to the VATrkers TEL NO SET BACK YARD HWY PROP LINE WIDTH Cortlperlsatcn prowatcrts of the Labor Code you must forthwith Ll.7NF1A FRONT comply with such proVl9gns or the permit shell be deemed revoked ADDRESS LIC NO PL LICENSED CONTRACTORS DECLARATION SIDE CITY LOC CLASS PL I hereby affirm that I am licensed underprwleare of Chapter B SEWER MAP d (commencirg with Section 7000)of Division 3 of the Business and SO FT SIZE NO OF STORIES NO OF FAMIIJE9 O Prolessore Code and my License Is m full force and enact NEW ❑ BK CIO pop. License Number Lc Class GE IPiKN��WORK ADD ❑ VALUAT1oN � Contractor Date L� r ! 5�� ALTER ❑ $�ago �6Mt IRT !r }i�G /t JYtCEMQf1 erT rn REPAIR ❑ I em exempt under 9eC tl�^ $ _ BGPC for the reason /1 C ` S�� DEMOL ❑ LOMA PIC A Date USE Ex9? S URM ❑ J..��......a�,,,,///// nature �J+� Air 'l m owner of the property or my employees with wages m &I" d Al 1It LDMA Perm• ZI them sole oanpereahon will do the work and the structure e T 1tY Fl F __�_C 1?1.'-:` not Intended or offered for sale (Section 7044 Business and72 Q Professional Code 1 wAL TIE APRICAIrr OR FURKE p I~T HM.QE A IUZAfma19 IAOEiMl �'(/r��j 1 I EI I J ❑ I All Owner Of the am exciLLMery MntrWb with OR A MO O VhIG A HALrrOOUa AUIEPoAL EOWL TO OR OPEATER THIN TIE property AMOINis sm M TIE HAZIfSOUa MATERYIB KOIOMTIOrI DUCE+ FINAL BY C toBmmd and Proore to construct the prgeet (Section 7044 res❑ I'q MUL 121 . 3 i Business end Professore Code) 2� _c 1wLL THE NTENOEO USE OF TRE BUa1W BY THE APPIKMT OR FROM E SOUrl CHECK L-1•= OOCUHNr BEOWE A RANT TOR G TFICTCIlON OR AwEOf1RW71 FAOM TIE T FOR CONSTRUCTION LENDING AGENCY cosy AIV auAury IANUOEMENI asrnlcT IscwoAOl SEE RRIgrnNO cREcxusr Fpfl a:S 11 t Hr,t�ir. I hereby affirm that there e e C which his p 19mEIrg agency for �s❑ Rp wy the per lam arceplthe work for WrllCh ttYe pertM aedied(SW IYYE nEAO TIE HARM PA�NTEfU IQJTAUinMOLCE AAO TIESWMCU14TY TYn t 3097 Civ C) aiEaaen I UroEesuAo w REaurE rs uioER TIE Los AHOELEs eourrrr eooE [Ir7[1[f-[i',l[I si iJr�7 Y � aMPTER}]0 }Z 11e011U1 Z ZO I Ap OOHCErWiO H/SAR00119 Lenders Address 1 �:� 1 FN11:24 o .awl I certify that I have read the application and atato under penalty g Of perjury that the above information Is correct I agree to ComPh' PC FEE PERMIT FEE $ with as Canty ordinances and State laws retailing to Wilding auction and rare utlRorue repreeentatum of the ccfmty y%UANCE FETE O 9 tat 1491r1D IIR18d property for I our m r BNESTIOATON FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE