HomeMy Public PortalAbout5335 ALESSANDRO AVE_Building__ APPLICATION FOR BUILDING PERMIT �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILD N DDREg$ 1 O
BUILDINGppQ_RSS J6
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Workers'Compensation Insurance,or a certified C ZIP
C p reof( ec.3800,Lab.C.)/� �v['!`/. _ _ `C��
P611�y No. �CQmpany�'�'���fG SIZ OF LO NO.OF BLDGO�N LO® LOCALITY ` `
❑ Certified copy is hereby furnished. NEAREST CROSS ST L L
ertified copy is filed with the county building inspection TRACT BLOCK LOT NO.
Vv depart t ,w ,w� USE ZONE MAP NO.
Dat�Applicant�/✓`A�/� O[ A O AP BOOK P� -2-
PARCEL r/ SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' owN J OO VU TE .NOVI 7� res No
COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL?
ADD ESS
(This section need not be completed if the permit is for one hundred _^ 4. 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 CITYG � z P�/ O �� /J
is issued, I shall not employ any person in any manner so as to ARCHITEC O ENGINE �
ER TEL.NO. d
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. 0,2 FI`DWELL UNITS
NOTICE TO APPLICANT: If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' C TOR TE .NO. _ .� SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith 1,0&) yZS FRONT
comply with such provisions or this permit shall be deemed
med revoked. ESS LI NO. P L
Z q 8
LICENSED CONTRACTORS DECLARATION clyv Llc. LAss PL o
I hereby affirm that I am licensed under provisions of Chapter 9 L.� SEWER MAP V
(commencing with Section 7000)of Division 3 of the Business and S. .SIZE NO.OF.TORES NO.OF FAMILIES C
Professions Code, my li a se is in full force an eff t. l/ NEW ❑ BK PG C
�1 D CRI IO OF4NORK _ ADD ❑ VAL ON o0 , WC.
License N Lic.Class ` � --- � Z/00
Contrac r Z c ` ALTER ❑ z
ElI am exempt under Sec. , `
B.BP.C.for this reason _ REPAIR0DEMOL El
Date: USE OF EXISTI LDG. URM 13LDMA P/C#
Signature 47WPMAL4T(PRINTr, T NO. _ LDMA Perm#
2
❑ I, as owner of the property, or my employees with wages as AD ` p =wa:
their sole compensation,will do the work and the structure is H _
not intended or offered for sale Section 7044, Business and O FINAL DATE Q 3307
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OC PANT HANDLE A HAZARDOUS MATERIAL 7
❑ I, as owner of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN -C J T'�'O S
Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY > _
- 63
licensed contractors to construct the project.(Section 7044, YES❑ No❑ t I)A; L
Business and Professions Code.) r.w
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING Aws NECK�
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH --
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST
FOR GUIDELINES. CHANGE a I II.i
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 HAVE READ THE HAZARDOU IALS INF ATION GUIDE AND THE SCAQMD
3097,CIV.C.). CHECKLISf
ERSTAND MY REQUI EMENTS UNDER THE LOS ANGELES i;
�. COUNTY CO TITLE 2, R 2.20 SE IONS 2. .100 THROUGH 2.20.140 CONCERNING I.:IJVI -'�,J EI,3 ,I ,� ff�11I
Lender's Name I OUS A LjINGAND ORO NIN ERMITFROMTHESCAOMD.Z.
� 59y i All L I°i I..
o Lenders Address OWNM0 s s_.a_'
o I certify that I have read this application and state that the above
information is correct. I agree to comply with all county PC.FEE PERMIT FEE /)^
or I
as and State I uilding construction,and l/XU Uj
¢. hereby a ho' epreSentatives of is County to enter upon ISSUANCE FEE /
the above- ned pr y for' pection purpose
¢ Q / o INVESTIGATION FEE TOTAL FEE
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SipneWre cent : DMe e .
SEE REVERSE FOR EXPLANATORY LANGU GE