HomeMy Public PortalAbout5037 ALESSANDRO AVE_Building__ APPLICATION FOR BUILDING 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, BUILDING ADDRESS M. �/��
or a certificate of Workers' Compensation Insurance,or a certitied 40ND.W'•��"
copy thereof (Sec. 3800,Lab.C.) CITY ZIP
�//1 LOCALITY��y�
Policy No. Company SIZE OF LCT NO.OF BLDGS.NOW ON LOT w
❑ Certified Copy is hereby furnished. a/X SIO NEAREST ROSS 5.T.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP No. e,.(
Date Applicant ASSESSO MAP ROOK PAGOE� PAR00 ? � /
.7 SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' Ow TEL NO.
COMPENSATION INSURANCE .7 WITHIN 1000 FT.OF SCHOOL? YES OF No
(This section need not be completed if the permit is for one hundred DDRESS
S DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100)or less.)
I certify that in the performance of the work for which this permit CITY- Z / �l�1 8
is issued, I shall not employ any erson in any manner so as t0 ARCHITECT OR ENGINEER TEL NO. IJ I
become subject to the Workers' o enS tion • STATISTICAL CLASSIFICATION APT CONDO
Date Applican ADDRESS CLASS NO. C9= DWELL UNITS
NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become Subject t6 the Workers CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith Ir
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. FRONTP 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 SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES d
Professions Code,and my license is in full force and effect. 303) NEW ❑ BK PG , 0
License Number Lic.Class
DESC TION OF WO ADD VALUATION V
(�
Contractor Date ALTER. ❑ $ cc
ElI am exempt under Sec. r REPAIR 1:1
Love��t,�'o /C oo .
B.&P.C.for this reason DEMOL '❑ LDMA P/C# W
Date: USE OF EXISTING BLDG. URM ❑ 9L
Signature Z
APPLIC N (PRINT) TEL NO. LDMA Perm# .... ".8
iL•l•i 8
❑ I, as owner of the property, or my employees with wages as ' Z
their sole compensation, will do the work and the structure is AD RESS
`;{t_ 7€
not intended Or offered for sale (Section 7044, Business and ,-OA-v FINAL DATE Q
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 7r
,
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J �
❑ I, as owner Of the property, am exclusively contracting with AMOUNTS SPECIFIED N THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY _{III AL 8335 m
licensed contractors to construct the project (Section 7044, Yes 11 No
Business and Professions Code.) �� �)I
WILL THE IN
USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE.A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ��,{i
CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR t: I�lyGE
GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ No
a the performance Of the Work for WI11Ch this permit IS ISSUed(Sec. IHAVEREADTHE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, t,..{; SJ {'- {_I { ,+fl •f•'aa�`•` '
TITL 2,CHAPTER 2.20 SE TIO .20.100 THROUGH AO.140 CONCERNING HAZARDOUS
3 Lender's Name MA RE TI N F NG A AE M ROM THE SCAOMD. { y:� 3 {j _!`i
o Lender's Address L
0 /OWNrR OR AGENT
o I certify that I have read this application and state under penalty
0 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
N with all county ordinances and State laws relating to building �. OJ
co co truction, and hereby authorize re esentatives of this County ISSUANCE FEE
co t rup th b v oned r erty for inspection purposes.
a ,
INVESTIGATION FEE TOTAL FEE
r 14--1U of Wiwm o,neem Dale . �/
SEE REVERSE FOR EXPLANATORY LANGUAGE