HomeMy Public PortalAbout5329 ALESSANDRO AVE_Building__ 1 APPLICATION FOA BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION
FOR APPLICANT TO FILL IN BUILD NG.ADDRESS
..I hereby affirm that I have a certificate of consent to s Insure, BUILDING ADDRESS
or a certificate of Workers' Compensation Insuranc r a certified ���
copy thereof (Sec.3800,Lab.C.) CITY + ZIP
17F-1"A&6 ��^ 7 LOCALITY
Policy No. Co ny SIZE OF LO A //)� /� NO.OF B DGS.NOW ON LOT
❑ Certified Copy is hereby f shed. ��✓ oC0(� / NEAREST CROSS ST.
❑ Certified copy is fil with the county building inspection TRACT i1 BLOCK LOT NO. ?
department. d /y USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
RTIFICATE OF EXEMPTION FROM WORKERS' OWNER �-�-y T Q TE NO.
COMPENSATION INSURANCE ,/lrL��/�J O�+a,01-< WITHIN 1000 FT.of SCHOOL? ves No
(This section need not be completed if the permit is for one hundred ADDRESS_ �� A rQ�
�� �! J /C DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100) or less.)
Y CITY �✓ ZIP y —4
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in an manner o a to
become sub' t the Workers'C sation L ARCHITECT OR ENGINES TEL NO.
�! STATISTICAL CLAWIFICATION APT CONDO
Date' � Applican ADDRES ,52pLp��j^o � n� CLASS NO. � 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 �r TEL gyp 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. A D SS -5.
Ar p L
LICENSED CONTRACTORS DECLARATION �! �/G G' SIDE
CITY A^ LIC ASS PL
I hereby affirm that.l am licensed underprovisions of Chapter 9 '(j SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SQ.FT"_SSIZE NO.OF STORIES NO.OF FAMILIES
Professions Code,a /Jy licenseisin full force and a fect. CAP NEW BK PG a
License Numb "� v/ Lic.Class DESCRIPTION OF WORK A!+ � ADD p VALUATION e aA , Q
Contractor ate a'l `a L/
ALTER ❑
El am exempt under Sec. a �M REPAIR ❑ $ 0
BAP.C.for this reason �jP� DEMOL ❑
LDMA P/C# W
USE F EX TING BLDG. Q�� �,
Date: URM ❑ jJ Z
Signature APPLICANT(PRINT)�l T N LDMA'Perm# a
❑ I, as owner of the property, or m mployees with wages as f^ � /�`� ""����f Z ACCT,°g
-,-• -� 50.50
their sole compensation, will he work and the structure is ADDR SS O ' ;����
22zS .PS"T' / .�
not intended or offered fo ale (Section 7044, Business and . FINAL DATE G i
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 1
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J g
❑ 1, as owner of property, am exclusively contracting witl� AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? a S
FINAL BY > ACCT°
licensed co ctors to construct the project (Section 70 4, YES❑ No +
Busines nd Professions Code.) 3�0� 1�1$°g�
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 1TEMS
CONSTRUCTION he
A Y COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES.
I hereby affirm that there is a constr on lending agency for YES❑ NO TOTAL :15 1 = 40
N the performance of the work for this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING �/ 15 0
° 3097, Civ. C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE S LES CQUNTY CODE, CHECK 1_ °�lJ
TITLE 2,CHAP 2. 0 SECTIONS 220.100 THROUGH .14 ERNI1 HAZARDOUS (` +'�
3 Lender's Name MATERIALS G AND FOR OBTIf�04N A P OM CAQMD, CHANGE .013
Q. Lender's Addre `
O OWNER O NT
oI certify I have read this application and state under penalty �yrtn i
0 of ry that the above information is correct.I agree to comply P.C.FEE U PERMIT FEE �p 0000-0001 12119,+`7e+
5
all Co ty ordinances and State aws relating to building �v' 38 i M 8:013
W co and her authoriz re ves of this Co ty ISSUANCE FEE J'!J�+2 1 AM 8:013
o e pon the above- e ti op r�lnspection r s� i
a 1 INVESTIGATION FEE TOTAL FEE
nature O1 A,,,-,,O.lwl Dal / I I /✓ (/• /D +
SEE REVERSE FOR EXPLANATORY LANGUAGE