HomeMy Public PortalAbout5731 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'
hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS p� S" L S
or a certificate of Workers' Compensation Insurance,or a certified RO
copy thereof(Sec.3800,Lab.C.) CITY ZIP8v LOCALITY
Policy No. Companys1-Alia; W ,
C17-ii-
SIZE OF LCT NO.OF BLOGS.NOW ON LOT
❑ Certified copy is hereby furnished.
NEAREST CROSS ST.
C1Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
depart ent. USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS � �✓O/
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO.
COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? ves No
(This section need not be completed if the permit is for one hundred ADDRESS
S. O,U DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED(3Y
dollars($100) or less.)
CITY ZIP
1 certify that in the performance of the work for which this permit ►,3
is issued, I shall not employ any person in any manner so as to gRCHITECT ORENGINEER TEL NO. , G L ✓✓
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFI ATION APT CONDO
Date Applicant ADDRESS CLASS NO.17 DWELL UNITS
NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR TEL NO, SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith /J , Z 2 ¢i d FRONT
comply with such provisions or this permit shall be deemed revoked. ADD ESS �) (� LIC.NO. P L >-
G� !/ J SIDE n'
LICENSED CONTRACTORS DECLARATION CITY G� LIC.CL&S PL O
I hereby affirm that I am licensed underprovisions of Chapter 9 C,4 ' `�503 SEWER MAP U
(commencing with Section 7000)of Division 3 of the Business and 80.FT.SIZE NO.OF STORIES NO.OF FAMILIES
Professions Code,and my li ense is in full force and effect. �, NEW BK PG OF-
License Number VLiC.Class DESCRIPTION OF ORK ADD ❑ VALUATION , tJIU
Contractor �� / 11A)Date 9�� OC r ALTER ❑ $ Off'd-O G••
N
❑ 1 am exempt under Sec. REPAIR ❑ z
BAP.C.for this reason DEMOL ❑ LOMA P/C#
Date: USE OF EXISTING BLDG. URM ❑
Signature APP CANT(PRINT) TEL NO. LDMA Perm# ACC $
g
C3 1, as owner of the property, or my employees with wages as L 28 Z a Z �i`.l_.� ayM c r
their sole compensation, will do the work and the structure is ADDRESS 0 ,x3 y 1I•-r=6_5
not intended Or Offered for sale (Section 7044, Business and O D FINAL DATE C ITEMS
Professions Code.) L�... A(o q(o
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE +
❑ 1, as owner of the property,-am exclusively contracting 44, AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 0 I I_I(AL 1175 - 6F5
licensed contractors to construct the project (Section 7044, -+r
Business and Professions Code.) YES❑ NO CHECK � ,65
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING �
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 00C:H( �(iF ,
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES.
I hereby affirm that there is a construction lending agency for YES ElNO Elr�{�!�i
the performance of the Work for which this permit Is Issued(Sec. IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING I_{000"'!,•0-0 j 4/ 8/96
3097, CIV.C.) 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 HAZARDOUS G (;� 92.35
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. 6J
Lender's Address
cr OWNER OR AGENT
3 1 certify that I have read this application and state under penalty /
(L of.perjury that the above information is correct.I agree to comply P.C.FEE - PERMIT FEE
m with all county ordinances and State laws relating to building
M construction, and hereby authorize representatives of this County ISSUANCE FEE
gto enter Ton.t above-mentioned property for inspecti/on ur s/es.
o / -' lf•�.�D INVESTIGATION FEE TOTAL FEE
N cQm111 I ADWi...I o Agent --^ Dale (�
SEE REVERSE FOR EXPLANATORY LANGUAGE