HomeMy Public PortalAbout4814 ALESSANDRO AVE_Building__ • --,.- 4PPLI%,1'%.;FION FOR BUILDING PERMIT
COUNTY OF LO`S 41GELES -&JILDING AND SAFETY
! 'BUILDING ADDR SS
.. WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN p
I hereby affisim that I have a certificate of consent to self insure, BUIL I D RESS d
or a certificate of Workers' Compensation Insurance,or a certified
copy thereof (Sec.3800,Lab. C.) lmft�lZIP
!7 'v LOCALITY
Policy No. Company S E OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. 14NEAREST CROSS S.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
Date Applicant ASS SS. MAP BOOK PAGEARCEL
V 3 SPECIAL CONDITIONS m J /
CERTIFICATE OF EXEMPTION FROM WORKERS' oW�NE TEL o. pp
COMPENSATION INSURANCE l6 Id' �O� WITHIN 1000 FT.OF SCHOOL? YES No
This section need not be completed if the permit is for one hundred ADDRESS
( P P M11C1ITECT1
/fes �!/1 ! DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100)or less.) ZII certify that in the performance of the work for which this permit 'Ole !is issued, I shall not employ any person in any manner SQ as t0 OR ENGINEER TEL NO.
become subject t0 the Workers'Compensation Laws. STATISTICAL CLASSIF CATION APT CONDO
Date Applicant ADDRESS CLASS N0. DWELL UNITS
NOTICE TO APPLICANT., If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject t0 the Workers' CONTRACTOR / TEL NO. SET BACK 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 SO.FjSIZE n NO.OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. OY NEW El BK PG , a
License Number Lic. Class DESCRIPTION OF WORK ADD ❑ VALUATION O
Contractor DateALTER $ �/ 0
El am exempt under Sec. REPAIR ❑ $ —=
B.&P.C. for this reason /
LGJL l 'G
OL ❑ LDMA P/C# _ W
Date: USE OF EXISTING BLDG. URM ❑ CO
CL
Signature APPLICANT(PRINT) TEL NO. LDMA Perm# Z
f 15(1, 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 W-,-.
± a LYM
not intended or offered for sale (Section 7044, Business and FINAL DATE Q r.
Professions Code.)
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
\ OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE _
\❑ I, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 'C11-+
J licensed contractors to construct the project (Section 7044, YES❑ NO❑ A 1
Business and Professions Code.) i!' ML_ � z
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH :""+••
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR Imo`:t': i a
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. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
N TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS r.
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. dS; !r 5 C,ly'•,`is
G_ _
o Lender's Address :-r < c
PM
O OWNER OR AGENT �-,i•i•` ••
o I certify that I have read this application and state under penalty
o P.C.FEE PERMIT FEE
of perjury that the above information is correct.I agree to comply JTO I .S �✓
o with all county ordinances and State laws relating to building
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construction, and hereby authorize representatives of this County ISSUANCE FEE
M to enter upon t ve-menti e prop tyq inspection purposes. fL
a INVESTIGATION FEE TOTAL FEE
r lure Olir2ni Or Agent ate
a / ."
SEE REVERSE FOR EXPLANATORY LANGUAGE