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�- APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING ANDrzAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUIL D E r
I hereby affirm that I have a certificate of consent to self Insure BUILDING ADDRtk
or a certificate of Workers Compensation Insurance or a certified
copy thereof (Sec 3800 Lab C) LOCALITY
Policy No Company SIZE OF LOT N F BLDGS NOW ON LOT
)
❑ Certified copy is hereby furnished NEAREST CROSS ST
❑ Certified copy is filed with the county budding Inspection T USE ZONE MAP NO
CT BLOCK LOT NO r
department
Date ApplicantES O M OOK AGE IL
Q SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS WNITIR
COMPENSATION INSURANCE C WITHIN 1000 FT OF SCHOOLS YES NO
(This section need not be completed If the permit Is for one hundred ADD ESS
0. � 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 �O y � 3
is issued I shall not employ any person In any manner so as to o
become subjectlto the Workers Com ensation Laws ARCHITECT OR ENGINEER TEL NO
p STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS _ CLASS NO DWELL UNITS
NOTICE TO APPLICANT If after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST I
Exemption you should become subject t0 the Workers CONTRACT TEL NO SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code you must forthwith
FRONT �
comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO P L
LICENSED CONTRACTORS DECLARATION SIDE
' CITY LIC CLASS PL
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 FT SIZE NO OF STORIES NO OF FAMILIES
Professions Code and my license is In full force and effect NEW BK PG
O WORK R TIOli. z a
License Number- Lic Class DESC � ADD ❑
VALU ON
Contractor DateLIQ W LTER $
❑ cc
1 am exempt under Sec REPAIR ❑ $ f 0
W 1�7s i
B&PC for this reason DEMOL ❑ LDMA P/C#
Date USE OF ISTING BLDG URM 1:1s ACCTe0)
Signature3303 108.90 Z
�( APPLICANT(PRINT) TEL NO LDMA Perm#
y(J I as owner of the property or my employees with wages as Z
! their sole compensation will do the work and the structure Is ADDRESS F MS
1 ITE
not intended or offered for sale (Section 7044 Business and FINAL DATE p TIITAL 10v0
Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 1+- ry
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J
ElI as Owner of the property am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY CHEM 10O1.90
licensed contractors to construct the project (Section 7044 VES❑ No❑ 4 1 00
Business and Professions Code) CHANGE
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING I
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHQCKUST FOR
GUIDELINES
I hereby affirm that there Is a construction lending agency for I YES❑ NO❑ 0000-0001 11/14/95
N the performance of the work for which this permit is issued(Sec , +c
NG
3097 CIV C) CHECKLIST I UNDERSTAVE READ THE NDUMYY REQUIREMENTSS MATERIALS NUNDERTION GTH LOS ANGELES COUIDE AND THE SCACMD ON TV COIDE 3304 1 PM 6-
3 ,
TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS
3 Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD 4 y
IL Lenders Address
ONNER OR AGENT
0 1 certify that I have read this application and state under penalty
0 of perjury that the above Information is correct I agree to comply j PC FEE PERMIT FEE X/ V
N with all county ordinances and State laws relating to building
const ruc n hereby authorize representatives of this County ISSUANCE FEE Q
to enter u e e mentioned pr erty for ins4e tion u os Q' 9
1� �� INVESTIGATION FEE TOTAL FEE O, / D
Q y
^ i rods� Age
LSEE REVERSE FOR EXPLANATORY LANGUAGE