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Home My Public Portal About4926 ALESSANDRO AVE_Building__ Vv APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELESBUILDING-AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING AD//DR ss I hereby affirm that I have a certificate of consent to self insure, BUI DI ADR S or a certificate of Workers' Compensation Insurance,or a certified. ° copy thereof(Sec.3800,Lab.C.) CITYr ZIP . LOCALITY Policy NO. Company SIZE OF LCT NO.OF BLDGS.NOW ON LOT �cIZ��JL �G� •C 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 CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO COMPENSATION INSURANCE AW C9 V- IACy ! WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADD y� dollars ($100)or less.) A � DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY I certify that in the performance of the work for which this permit CITY , �, Zlp�a/` �� is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER (!!AA/ TEL NOWO become subject tO-the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date�c Applicant ADDRESS CLASS NO. , ag/ DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject to the Workers' CONT �9_/ TE N /(� SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith ,0)v /Z1 •. ,* lJ y, FRONT comply with such provisions or this permit shall be deemed revoked. DE'St,�ti N �� PL }� LICENSED CONTRACTORS DECLARATION l !Y V SIDE O CITYj� LIC.CLASS P L U I hereby affirm that I am licensed underprovisions of Chapter 9 `L�— SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORIES NO:OF.FAMILIES Professions Code,and my license is in full force and ffect. NEW ❑ BK PG O License Number Lic.Class DE CR NOFJvtORK ADD ❑ ]�(f� VALUATION U LIJ Contractor e0ate © r ALTER ❑ $ r�O""� N 44 ❑ 1 am exempt under Sec. � e� r© f aAd REPAIR ❑ Z x,111 B.BP.C. for this reason DEMOL ❑ DMA P/C# - Date: USE OF EXISTING BLDG. URM ❑ Signature APPLICANT(PRINT) TEL s. 11_Ts1 ❑ I, as owner of the property, or my employees with wages as Z b_, �.,I,cr their sole compensation, will do the work and the structure is ADDRESS O =5 •= _— not intended or offered for sale (Section 7044, Business and FINAL DATE a ;F ` Professions Code.) r/2�i p WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL "(' ! .g .�y�.—. g•� ❑ 1, as owner of the y, Y g OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q }[_ tl �`�8 &.._,'� property, am exclusive) contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? I 3 2 licensed contractors to construct the project (Section 7044, FINAL BY > -I.-)t c1w Business and Professions Code.) Es❑ No❑ ;HE{;K WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING �" {' OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 1•H>=ME .00 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKUST FOR GUIDELINES. I hereby affirm that there is.a construction lending agency for YES❑ No❑ the performance of the work for which this permit is issued(Sec. I�j IO ISI yj y /�?:} 3097,CIV.C.) [HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, �nTITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS ? RI m Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 4991 y A 1 04 m Lender's Address Q OWNER OR AGENT 3 1 certify that I have read this application and state under penalty EL of perjury that the above information is correct.I agree to.comply P.C.FEE PERMIT FEE with all county ordinances and State laws .relating to building m nstruction and a eby authorize repr sent fives of this County ISSUANCE FEE enter up the a tinned pr ert or.i spection urposes. 6 p� INVESTIGATION FEE TOTAL FEE 0 N wNre of Applicant or Agent Dale SEE REVERSE FOR EXPLANATORY LANGUAGE t;.