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Home My WebLink About0895A 0896AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self Insure. or a certificate of Workers' Compensation Insurance, or a cc tied cmy thereof (Sec. 3800, La . C.) Policy No. -76 /O Company +� Certified copy is hereby furnished. Certified copy is filed with the county building inspec- lion department. DaleApplicon RTIFI TE OF EXEMPTION FROM WORKERS/ COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation laws. Date - Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number 2-L Class Cantracto N Date I am ex mpt nder Sec. B.f1P.C. f Fris-ree n OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from th Contr tar's License Law for the following reason (Section 7031.5, Business and Professions Code): I, as owner of the property, or my employees with wages. as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that 1 have read this application and state that the above Information is correct. I agree to comply with all County 'Mand StatelawsreloUngtobuildinthor"e representativesofthise-mention rape", for Inspection purponses, Signature of Applicant. Agen >so - APPLICATION FOR BUILDING PERMIT] COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN Aooaess X141 J,jm o - BUILDING �7 ADDRES!i Cc CITY ZIP LOCALITY �4...✓ �.w. Gni NO. OF BLDGS. NEAREST / SIZE OF LOT NOW ON LOT CROSS ST. /✓` P/i. ' ASSESSOR TRACT BLOCK LOT NO. I PAGE PARCEL OWNE TEL. NO.a2 USE Z�O7 E OP J _J ADDRESS. [nJ (,/I SPECIAL CONDITIONS CITY ZIP / S ARCHITECT OR TELDISTRICT GROUP TYPE FIRE PROCESSED BY ENGINEER NO. CONST.'` ZONE ADDRESS •a`� T,.1.. CONTRALTO TEL. NO. / STATISTICAL CLASSIFICATION APT. NDO. [CyyIO CLASS NO. —.22 DWELL. UNITS ADDRESS LIC. SEWER MAP CITY A. CLASS BK PG VALIDATION SO. T. NO. OF NO. OF CHECK SIZE STORIES I FAMILIES ONE DESCRIPTION OF WORK NEW ❑ VALUATION O>y ADD i ' D 8 9.5 A t� ALTER a 3 USE OF REPAIR f I•• 2 S O O EXISTING BLDG. G DEMOL •° 2 S 0 O 5 APPLICANT- PRINT ex✓ TEL. NO. &.T-/ F/ FINAL +;r1� 7 I DATE (/ .J 0 R20-87 ADDRESS Y1,5,6 f- t. ! 65 FINAL IPRMNI By BUILDING ADDRESS LOCALITY ' :20 8 9.6 A MOVING - TEL. • • • .• CONTRACTOR NO. ) -3675 ADDRESS REQUIRED -YARD HW1' SET BACK TOTAL SETS K PROP. LINE WIDTH .... • ° ° 3 6 7 5 E FRONT = 0820-87 PA, SIDE P. L. LDMA Ref. R P.C. Fee $ Permit Fee •CSG•S Issuance Fee I U •' LDMA P/C fl Investigamn Fee 34r S' Total Fee / IDMA Perm, M SEE REVERSE FOR EXPLANATORY LANGUAGE it, 0" N F.K-IWII,Ul.k -DEC1. ARA I [0\ 1 ,by afl d' I a,, --v,' _p' I r lee :,z Lam f-.. 4,e Wlo ^9 } a (SOc 7031 5) .,nd7CJ.-.,xinnrf.'adl!Anr<in�nr, r,hubi;b r 71 -1` r \ / zr'.t-t stnrr r, eltct ,parr n:iy rrrxatrnn.mor n, it, eu5r..,,aA, r, qui rbc appli—I 1 r/ ry•rreir to /d c • l tan•rnenI - thathrish. JJ r- ni to Torp i. ibc fr., fat I,.r .n!1/f< n .nr, virl tinn�'p(1ft1,r / Ut r tnn i 1 the 8asr r �, andJ' / . v s `'c',ii(t'/ nr d•ar L Nr >cnrpr tl ere/rn. r1dJ tbr• h,1,r rhe . allr,t•td ...... pfs n, AY vi lannn r/,lrihnn-+r31.S by � c pph.dnt /nru pr rn t AJ rt flr rJj1-mtt ✓ ! - pt alfv nl not Hal - m than/ 1 end d d f! rs tS 5(0.): I, as o nee of ti,e p open) or "y employ ,w rtt wagon ns, the, Snle cnmF snt nn, -I! d; il-r-. o ald fha St•ucture is not mi—dod or off mf,d fo, sale (5r< 704-1) lis c ant Pen/ruiou. C /r: 7he Cont— Lit—, - I r d,rs not appfV n, a n ...<nrr a/ pn,prrtt ..1 n l"iU, tJnnprn r, s thrsrnn, and u / ... d 1 u ,ri. hinttr.//or ,—gl.,_ hie nem rap/{tr+r, pn,rid,d that garb na. pravementr arr not intended nr uIjrr d Inv rale. i ever, for hu Udin,r ar hope...+.seen! is -Id rvilhin nnr year of trumpf.mmm, tho nu nrr•FuiF.lrr a ill ben r the ye- n(pror i t• that by did not Iwi1J nr imprrn r fnr t!, purpose of a! •J. - .. - I, as owner of the p operty, am e.,lr.lvety'cen•wc- ting wtlh Ir..m,sed m'I'mtor, to co"I'b 1 rhe peeled (S- 7044) 17ucinesv anJ Yen/resiour Cr,Je- Thr (.nnfrarfru's l.ire6\ Lau•dors nor-ajpf} to an .,ba _- h lal, pr i pr Ilrr lul t r •nts/nr rnah tl d d a 7a trPf J)l ,q`n !�I �s u;tn! la fhr (, ate<i<tror i La. xir 7.i. •T � ' I om exempt under 5ec. . E-&P.C. for this Dote O>, PLANS TO APPLICANT INSPECTOR'S NOTES To: Approved- No. Dm - No. Datc • - - , - _. App -1, Reymrod \_•• `• •Dates Re<civod or Approved - .. -. _ - _ - __. ._ . _ ... .._ r .. _ ... c c- - t Fi•e Depc:r•t ` Ped -I Ian P.OteC11On -, - , -. C \'•�•,• 1 \15�: \ 1 �; I�.n nr I ;•,lascnrvl (]VIdirlg) al Dranonn I - -- -- _ Pa, I, nn \ Approvols Dote -" Inspector's Signature fS�•t..: t & Yards) Energy In•:u ln•,on _ a.� I 4 Lath - Ea lona, Correct fi P.m.d .. - . • + ,'.. E en Fronr s -, 0" N F.K-IWII,Ul.k -DEC1. ARA I [0\ 1 ,by afl d' I a,, --v,' _p' I r lee :,z Lam f-.. 4,e Wlo ^9 } a (SOc 7031 5) .,nd7CJ.-.,xinnrf.'adl!Anr<in�nr, r,hubi;b r 71 -1` r \ / zr'.t-t stnrr r, eltct ,parr n:iy rrrxatrnn.mor n, it, eu5r..,,aA, r, qui rbc appli—I 1 r/ ry•rreir to /d c • l tan•rnenI - thathrish. JJ r- ni to Torp i. ibc fr., fat I,.r .n!1/f< n .nr, virl tinn�'p(1ft1,r / Ut r tnn i 1 the 8asr r �, andJ' / . v s `'c',ii(t'/ nr d•ar L Nr >cnrpr tl ere/rn. r1dJ tbr• h,1,r rhe . allr,t•td ...... pfs n, AY vi lannn r/,lrihnn-+r31.S by � c pph.dnt /nru pr rn t AJ rt flr rJj1-mtt ✓ ! - pt alfv nl not Hal - m than/ 1 end d d f! rs tS 5(0.): I, as o nee of ti,e p open) or "y employ ,w rtt wagon ns, the, Snle cnmF snt nn, -I! d; il-r-. o ald fha St•ucture is not mi—dod or off mf,d fo, sale (5r< 704-1) lis c ant Pen/ruiou. C /r: 7he Cont— Lit—, - I r d,rs not appfV n, a n ...<nrr a/ pn,prrtt ..1 n l"iU, tJnnprn r, s thrsrnn, and u / ... d 1 u ,ri. hinttr.//or ,—gl.,_ hie nem rap/{tr+r, pn,rid,d that garb na. pravementr arr not intended nr uIjrr d Inv rale. i ever, for hu Udin,r ar hope...+.seen! is -Id rvilhin nnr year of trumpf.mmm, tho nu nrr•FuiF.lrr a ill ben r the ye- n(pror i t• that by did not Iwi1J nr imprrn r fnr t!, purpose of a! •J. - .. - I, as owner of the p operty, am e.,lr.lvety'cen•wc- ting wtlh Ir..m,sed m'I'mtor, to co"I'b 1 rhe peeled (S- 7044) 17ucinesv anJ Yen/resiour Cr,Je- Thr (.nnfrarfru's l.ire6\ Lau•dors nor-ajpf} to an .,ba _- h lal, pr i pr Ilrr lul t r •nts/nr rnah tl d d a 7a trPf J)l ,q`n !�I �s u;tn! la fhr (, ate<i<tror i La. xir 7.i. •T � ' I om exempt under 5ec. . E-&P.C. for this Dote O>,