HomeMy Public PortalAbout4920 ALESSANDRO AVE_Building__ APPLICATION FOR BUILDING. PERMIT
COUNTY OF LOS ANGELES S„. 1` ” BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT,TO FILL AN BUILDING ADDR SS /
I hereby affirm that I have a certificate of consent to self insure, B I G ADDRESS ® LJ iv
or a certificate of Workers' Compensation Insurance,or a certified ^_�
copy thereof(Sec.3800,Lab.C.) // ZI / LOCALITY
Policy No. - Company SIZE OF LCT L C. NO OF SLOGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CROSS ST.
❑ Certified copy is filed with the County building inspection TRACT) { BLOCK' LOT NO.
department. ` �✓ 13 - USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BtGGll77 Dt,D 66PAGE "b73
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER `'
COMPENSATION INSURANCE `� l� WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the,permit is for one hundred A DFUS DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.). /Vl
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I certify that in the performance of the work for which this permit ZIP
cy
is issued,'f shall not employ any person in any manner so as to HIT Q NGIN i become subject to the Workers'Compensation Laws. STATISTICAL CLA SIFICATION APT CONDO
Date Applicant y � O -/ CLASS NO.. � DWELL UNITS
NOTICE TO APPLICANT.' If, after making this Certificateof OOYY REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' �' _ 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. q ELIES LI .NO. P L }
I
LICENSED CONTRACTORS DECLARATION 2 "r PDE 0
LIC.CLASS P L
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and T IZE NO. STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. NEW C3PG O
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License Number LiC. Class DES RIPTI RK. ADD VALUATION ,
3 W
I Contractor Date ALTER ❑ In
j ElI am exempt under Sec. REPAIR C3 $ z
BAP.C. for this reason DEMOL ❑5�2::JAK4 009F LDMA P/C#
Date: ftAPPLICAoft
NG l- URM ❑Signature INT) - TEL NO. LDMA.Perm#
❑ 1, as owner of the property, or my employees with wages as
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i their sole compensation, will dothe work and the structure is ADDRESS 0 0. C" i:Ca )
not intended or offered for sale (Section 7044, Business and FINAL DATE X307 'E€•J=• 'U
rofessions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL t J
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE {{{Y.••
as owner Of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY / •g•
licensed contractors to construct the,project (Section 7044, !� s _'
i
Business and Professions Code.) NES El NO❑ •^^SS-�
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING L.e30
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
'CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR 22 !T M`'_
I GUIDELINES. -
I hereby affirm that there is-a construction lending agency for YES❑ No❑ Th
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the performance Of the Work for which this permit IS ISSUed(SBC. I HAVE RE AD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PE RMITTING '` �•
3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, - t,€-iEEECK 711-D4.97',
' TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS
m Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMO, CHANGE ^j€`�
m _
Lender's Address
OWNER OR AGENT
3 1 certify that I have read this application and state under penalty
a. P.C.FEE PERMIT FEE - "'�• f ;:; '
C3 of perjury that the above information is correct.1 agree to comply r® �d �'j S,;€�€�€I—!,1€fI€1 y;/ /96
In with all county ordinances and State laws relating to building +�J • ` /
m construction, and hereby authorize representatives of this County ISSUANCE FEE A /,O :h`w t 1 tit lad-=.-
2 to enter upon the ab ve-mehtio a rty for inspection purp ses. j
b � INVESTIGATION FEE TOTAL FEE /
01 row=a o Da �y T /
SEE REVERSE FOR EXPLANATORY LANGUAGE