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HomeMy Public PortalAbout5839 ALESSANDRO AVE_Building__ APPLICATION FOR BUILDING PERMIT , �] COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER S`COMPENSATION DECLARATION FOR APPLICANT TO FILL IN i BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self Insure BUILDING ADDREt$S - r} r✓� or,a certificate of Workers Compensation Insurance or a certified copy thereof(Sec-3800 Lab CC) �J1 CITY ZIP Policy No I df' 1 n ocla-g ! Company 6� te N Te I LOCALITY �^ a SIZE OF OT N(.�OF i LDGS NOV ON LO�, NEAREST CROSS ST .� Certified copy Is hereby furnished - ,�J� � � P/,k- �� El Certified copy is filed with the county building Inspection TR^ 5 BLOCK OT NO�� y department .// USE ZONE M P NO Date+Gam✓Applicant�d�/`- U/�i1/ ASSESSOR MAP BOOK Z PAGE J �PAGCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS OWNER 3 Jl►/ TE No 0 COMPENSATION INSURANCE S Q C Q WITHIN 1000 FT OF SCHOOL'S YES No (This section need not be completed If the permit Is for one hundred ADDRESS ft 11 �^1,/ r dollars ($100)or less) W! r r {�1 DISTRICT GROUP TYPE CONST FIRE ZONE PROCE D BY I certify that in the performance of the work for which this permit CI Y Q 1 1 n zIPgl,7 „y IS issued 1-Shall not employ any person m any manner SO aS t0 ARCHITECT OR ENGINEER TEL NO '` - aJC become subject to the Workers Compensation Laws - STATISTICAL CL SIF CATION - APT CONDO - Date Applicant ADDRESS CLASS NO DWELL UNITS NOTICE TO APPLICANT If after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption you Should become Subject t0 the Workers CONTRACTOR TEL NO //gy�pp C SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code you must forthwith 6`, r r V O Q�J FRONT comply with such provisions or this permit shall be deemed revoked DDRE /S� ^tt LIC NO p L - N - It U DY' 10J�1 d� ' y SIDE - - LICENSED CONTRACTORS DECLARATION - Y LIC CLASS-B 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 Professions Code and my license Is In full force and effect I I t NEW ❑ BK PG ' >_ License Numb r LIC Class L DESCRIPTION O WORK ADD ❑ VALUATION EL Contractor Date 3�3Q` q� C32" �t ALTER 20C,)L3 O �h 0 ElTec, r. 1 I am exempt under Sec REPAIR , $ F_ B&PC for this reason d fg DU Y` I DEMOL ❑ LDMA P/C# III Date USE OF EXISTING RI DG7 URM ❑ i CL ` Signature LI�AtyT(PINT)© TEL NO (}^�s/ LDMA Perm# Z j a Z ❑ I as owner of the property or my employees with wages as G (cl IOr✓ A`C T.,r their sole compensation will do the work and the-structure Is DRSS O not Intended OF'offered-foF sale (Section 7044-Business and rowhe" t 1(D OOH t W/ FINAL DATE Q 307 "t.4 . I� Professions Code) D WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL � / + � i 7' c}e�f ❑ I as owner of the y Y g OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J 1 1TGI S property am exclusive) contracting with FINAL BY j r licensed contractors t0 construct the project (Section 7044 � AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE Business and Professions Code) YES❑ NO 0' _ TOTAL 421 - 02 WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING 11�L r CHECK /.-i.t Iy OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH t t C HE f T 1 -] CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT ISCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES �/ t + z CHANGE .0 I I hereby affirm that there Is a construction lending agency for YES❑ ` NO µ V T7F111V s N the performance of the work for which this permit Is issued(Sec T- "� - 3097 CIV C) IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING N CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE Lenders Name TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS 3 MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD o Lenders Address 8959 1, AM 4;y 7 p OVMER OR AGENT o I certify that I have read this application and state under penalty - of perjury that the above information Is correct I agree to comply PC FEE PERMIT FEE with all county ordinances and State laws relating to building m construction and hereby authorize representatives of this County ISSUANCE FEE co t er upon the ay/)ove Dned property for Inspect) n pu^^o__ es a �[ � .��"1. i "[ INVESTIGATION FEE TOTAL FEE � /' D 1°s�q` of APP/I e�a Ap D �" LM P� ate r SEE REVERSE FOR EXPLANATORY LANGUAGE