HomeMy Public PortalAbout4929 ALESSANDRO AVE_Building__ APPLICATION FOR" BUILDING PERMIT �1
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESSJi PjLL /J J
BUILDING ADDRESS _ • ''
I hereby affirm that I have a certificate of consent to self insure, / Awl
or a certificate of Workers'Compensation Insurance,or a certified CI Zlp /�,- -e '
copy thereof(Sec. Lab.C.) //�j _ LOCALITY
Policy NO. �d Company A ^ � d1 SIZE OF LOT NO.OF 8LDG,5.NOW ON LOT
NEAREST CROSS ST. 01 A l u�A
❑ Certified copy is hereby furnished. 521/11 Y` �'(
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
depart ant. 4-7±--- USE ZONE MAP NO.
ASSESSOR MAP BOOK PAGE PARC L
Data Applicant ---- 1[tSi>_ 3 —33SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER/V j EL NO.
COMPENSATION INSURANCE U r " �V WITHIN 1000 FT OF SCHOOL? YES No
(This section need not be completed if the permit is for One hundred 5 N0[VU'•� kDISTRICT - -GROUP TYPE CONST.' FIRE ZONE PROCESSED BY
dollars($100)or less.) ITY ZIP /
I certify that in the performance of the work for which this permit ru. e q r.! [ 1.0 is issued, 1 shall not employ any person in any manner so as to ARCHITECT OR NGINEER TEL.NO.become subject to the Workers'Compensation Laws. TISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS ASS NO. -2-1 DWELL UNITS
NOTICE TO APPLICANT: If, after making this Certificate ofCONTRA � REQUIRED TOTAL SETBACK FROM EXIST
R
Exemption, you should become subject to the Workers' �" T �v� SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith TEL.NO. FRONT
comply with such provisions or this permit shall be deemed revoked. DRESS LIC.NO.4" PL
' SIDE a
LICENSED CONTRACTORS DECLARATION ell - LIC.CLASS
PL o
I SE
hereby affirm that I am licensed under provisions of Chapter 9 WER MAP v
(commencing with Section 7000)of Division 3 of the Business and SQJ-7_$IZ� NO.OF STORE NO.OF FAMILIES O
Professions Code,and license is in full force and effect. //TT1Ill TT��II NEW ❑ BK PG I••_,
DESCRIPTION OF WORK ADD VALUATION , W
License Numba Lic:Class 11 (� IllAJ 4
Contractor Date 'Z k1l ALTER ❑ $� ���' b� z_
b W_q0 REPAIR ❑
❑ I am exempt under Sec.
BARC.for this reason DEMOL ❑ LDMA P/C#
Date: USE OF EXISTING BLDG. URM. ❑
3
Signature APPLICANT(PRINT) TEL.NO. LDMA Perm# A, .
Z w t,I :•s-
❑ I, as owner of the property, or my employees with wages as O _ _
their sole compensation,will do the work and the structure is _ i_j M. _
p ADDRESS Q116 9 1!:_,{
not intended or offered for sale Section 7044, Business and FINAL DATE _
Professions Code.) A,iG7
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN pp `''
❑ I, as owner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY � e t_I AL 3' 0 o 38
licensed contractors to construct the project.(Section 7044, YES El NO El Business and Professions Code.) ;f L{":' '_' _
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING %
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTHr.I •i{(� F{i,
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST :.{J t,.,E
FOR GUIDELINES.
I hereby affirm that there is a construction lending agency for YES ElNo Elthe performance of the Work for Which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD j
3097,CIV.C.). - PERMITTING 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
o Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. 17 + e r'j"j
Lender's AddressOWN���� 1, r_ i i
o 1 certify that I have read this application and state that the above
information is correct. I agree to comply With all county RC.FEE PERMIT FEE. `v/
ordinances and State laws relating to building construction,and
a- hereby authorize representatives of this County to enter upon ISSUANCE FEE
the abgZe-menti ed propert or inspection purposes.
a INVESTIGATION FEE TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE.