HomeMy Public PortalAbout5233 ALESSANDRO AVE_Building__ f
APPLICATION FQ )5UILDING PERMIT
COUNTY OF LOS ANGELES ~' BUILDING AND SAFETY
'WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self insure, 6UILDINNSa�D{]!\E �� r 3 G►1nQS
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof(Sec.3800,Lab.C.) C v ZIP / '7F6
LOCALITY
Policy No. Company SIZE OF LC NO.OF BLDGS. WON LOT v `
El Certified copy is hereby furnished. NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department.
USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
WNER4
CERTIFICATE OF EXEMPTION FROM WORKERS' � � '�j 6'
COMPENSATION INSURANCE �R�, w�- yCs-�W WITHIN 1000 FT.OF SCHOOL? YES No
(This section need not be completed if the permit is for one hundred AD a� ) /X� Tsy�• DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100)or less.) " T ��J T-Y�
I certify that in the performance of the work for which this permit CITY ZIP
CA VIA
is issued, I shall not employ any person in any manner so as t0 AR OR ENG EER
become subject to the Workers'Compensation Laws. ���- � STATISTICAL CL2S1IFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. 1 DWELL UNITS
NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject t0 the Workers' CO RACTOR J€L NQ SET BACK
Compensation provisions Of the Labor Code, you must forthwith _ iS`�• YARD HWY PROP LINE WIDTH
.� TJ FRONT
comply with such provisions or this permit shall be deemed revoked. ADD S_ L/y�yty�0 P L
a! °� :h-�� 4(�`� '✓c•-�� SIDE
LICENSED CONTRACTORS DECLARATION C sN� LIC.CK P L
I hereby affirm that I am licensed underprovisions of Chapter 9 ✓/' QnA SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STOR S NO.OF FAMILIES 0
Professions4Cde,Cn�dnglicense is in full force and ffect. NEW ❑ BK PGULicense Nu „ Lic.Class DESCRIPTION OF WORK > ADD VALUATIONC}Contractor Date f” ALTER �, $ 2 U0C� �'''^``=s O
- REPAIR ❑❑ 1 am exec. $ - -- U
BAP.C. for this reason DEMOL 1:1W W
LDMA P/C# _
Date: USE OF ISTI B , URM ❑ I _ :..L �•�c_� _ ._�;;--f Z
Signature APPLICANT(PRINT)}) TEL NO. LDMA Perm# Q.
' i„ F .I;• ^'`r
❑ 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 O
not intended or offered for sale (Section 7044, Business and FINAL DATE n AProfessions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL M--N-pr-
1, as owner of the property, am exclusively contracting with
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE "'I ii yy [c'-S"' I• ' ! �-:"^_•
❑ AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? Q i1.7�,•"„+ I_I-`i '- ^t, '
licensed contractors to construct the project (Section 7044, FINAL BY
ves El No ElBusiness and Professions Code.)
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING mei! •c•, la n
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH �� -- -' -
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR ` ^ ( ,_ 4 .1 7-
GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ No❑
a the performance of the work for which this permit is issued(Sec. �, j-' — -�°�
p� I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING - , _ _
N 3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS �jt'%I - --•`• '
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD ✓// + _.�, l:-
o Lender's Address H.?i
O OWNER OR AGENT
o I certify that I have read this application and state under penalty
4 of perjury at the above information is correct.I agree to comply P.C.FEE PERMIT FEE
a with all unty ordinances and State laws relating to building r - -•-• '
co
construe n, and hereby authorize representatives of this County ”.5� ISSUANCE FEE Co -:cC:•I I § �=
to enter n above- nt ned prop .ty for inspection purpos s. 2 C . 4-0
\ =
Q_
� INVESTIGATION FEE TOTAL FEE
c4eewc.I Aouroam o,AU Dale2-410.
SEE REVERSE FOR EXPLANATORY LANGUAGE