HomeMy Public PortalAbout5716 ALESSANDRO AVE_Building__ APPLICATION FOR BUILDING PERMIT �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APP (CANT TO FILL IN BUILDING R /
BUILDIN ` U
eby affirm that I have a certificat of consent toTself in ure, �-
o cert'icate of Work rs'C pens Ion ranc or a cerjfif
Cl ZIP
LOCALITY
SI O L
NO. BLDGS.NOW ON LOT
❑ Certified copy is hereby furnish NEAREST CROSS ST.
❑ Certified copy is filed with e C ty b ildiDipCtion TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
ASSESSOR MAP BOOK PAGE PARCEL
Date Applic SPECIAL CONDITIONS _
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER �� YES NO� /
COMPENSATION INSURANCEWITHIN 1000 FT.OF SCHOOL?
ADDRESS
(This section need not be completed if the permit is for one hundred DISTRICT GROUP CONST.' FIRE ZONE PROCESSED BY
dollars($100)or less.) CITY zIP /
I certify that in the performance of the work for which this permit
is issued, I shall not employ any,person in any manner so as to ARCHITECT OR ENGINEER TEL.NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLLAASSSIF CATION APT CONDO
Date Applicant ADDRESS CLASS NO. v 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 T O 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 S LIC N P IL
SIDE CL
LICENSED CONTRACTORS DECLARATION CITY LIC.CLAS PL o
I hereby affirm that I_ am licensed under provisions of Ch ter 911 SEWER MAP v
(commencing w'h io 7 Division 3 ojjj�77t11he,,��pps' a and SQ.FT.SIZE NO.OF STORES NO.OF FAMILIES O
Professions C d s in full forc>�and%ff�ct: NEW El BK PG
License Nu Lic.Classl�h D RI TION OF R ADD ❑ VALUATIQ �?l ly
CJ a
ti
Contracto Date ALTER El $ Z
❑ I am exempt under Sec. * REPAIR El�r ❑
B.8 P.C.for this reason DEMOL LDMA P/C#
Date: FUSFEJOF7&EXISTING BLDG. URM ❑ s
Signature APPLICANT(PRINT) TEL.NO. LOMA Perm# Z
El 1, as owner of the property, or my employees with wages as p
their sole compensation,will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DATE// � i ,�s�•3�_
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL —^
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL.TO OR GREATER THAN Q t i?��t?L. "h._._;,r ?r as '`•,...€•'
El 1, as owner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project.(Section 7044,
Business and Professions Code.) ves❑ No❑
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH i.• I':"!'?( w e�.i'_
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST
FOR GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ NO El
the performance of the work for which this permit is issued(Sec. s?i !iii-;_qj:g'3 _,' '"
3097,CIV.C. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD
). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES
m. COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING
Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
a Lenders Address OWNER OR AGENT
o I certify th I have read this 'cation and state that the above P.C.FEE PERMIT FEE
informati n is c rect. agree comply with all county AI,
ordinan es and t to I s r lacing t building construction,and
a. hereb uthor' a epresen i of this County to enter upon ISSUANCE FEE
.
�theae-me ' o or' spection purposes. 6
INVESTIGATION FEE TOTAL FEE
_tadt' of AVW ,or Agent Deb
SEE REVERSE FOR EXPLANATORY LANGUAGE