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Home My Public Portal About6111 AVON AVE_Building__ I APPLICATION FOS, BUJLDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDQESS I hereby affirm that I have a certificate of consent to self insure, BUI(/DING DRESL%�C� or a certificate of Workers' Compensation Insurance,or a certified `'�� CI � e 'copy thereof(Sec.3800,Lab.C.) � ZIP LOCALITY Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT �! ❑ Certified copy is hereby furnished. - NEAREST CROSS ST ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONEMAP NO. department. Date Applicant ASSESSOR MAP OpK PAGE PARCEL fC/7J Q� E.l��}j SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWN R E a J COMPENSATION INSURANCE /V� �/ WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred A RE S f� dollars ($100) or less.) Ao V 11 DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY. I certify that in the performance of the work for which this permit CI ZIP C//7/— ` is issued, I shall not employ any person in any manner so as to to 1 become subject to the Workers'Compensation Laws. AR TE T OR ENGINEER TEL No. J P STATISTICAL CL S ATION APT CONDO Date Applicant A DRESS /�y/� CLASS NO. DWELL UNITS NOTICE TO APPLICANT It, after making this Certificate of 0 �'^ REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL No. SET BACK YARD HWY PROP LINE WIDTH you Compensation provisions of the Labor Code, ® �must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION PILE CITY LIC.CLASS 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 S .SIZE NO.OF ST IES NO.OF MILIES Professions Code,and my license is in full force and effect. .� NEW ❑ BK � PG /�9 d DESC TION OF WORK VALUATION License Number Lia Class ADD ❑ 0 Contractor Date C� ALTER ❑ $22TO U ElI am exempt under Sec. , REPAIR ❑ BAP.C. for this reason DEMOL LDMA P/C# W Date: USE OF XISTING 5DG. G-�+ URM ❑ i 7 SignatureAPP T(P T r_ LDMA Perm# ' z \ I, as owner of the property, or my employees with wages as 6 E _ ,.. their sole compensation, will do the work and the structure is AD KESS 0 not intended or offered for sale (Section 7044, Business and S T FINAL DATE Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL �•— f OROA FIy1IXTURE CONTAINI HAZARDOUS'MATERIAL EQUAL TO OR GREATER THAN THE J f " c I, as owner of the property, am exclusively contracting WItJI AM SPECIFI D HE HAZARDOUS MATERIALS INFORMATION GUIDE? Q 'e'f ,;( T a ,_� �l FINAL BY t :I_+t,ir •.-° licensed contractors to construct the project (Section 7044, YES❑ No r •;E: c3 Business and Professions Code.) WILL THE INTENDED USE OF T BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERM OR CONSTRUCTION OR MODIFICATION FROM THE SOUTH q _ _ '- -N CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MAN MENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR P � GUIDELINES. _ I hereby affirm that there is a construction lending agency for YES❑ NO a the performance of the work for which this permit is issued(Sec. - 01 I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMQPERMITTING _Ij 3097,CIV.C.) �HECKCIST:I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, N TITLE 2,CHAPTER-2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS �• Lender's Name MATERIALS REPORTING•AND FOR OBTAINING A PERMIT FROM THE SCAQMD. ,- o Lender's Address O OWNER OR AGENT o I certify that I have read this application and state under penalty of perjury that the above infor ation is correct.I agree to comply P.C.FEE PERMIT FEE / r� with all .county ordinances a d State laws relating to building /V�1 m construe o a d hereby auth e representatives of this County ISSUANCE FEE to enter nth o -menti d property for inspection purposes. d(O c ••77 //�� INVESTIGATION FEE TOTAL FEE 2 r- Si9rta1ure tApp1,W.ren, VDa � SEE REVERSE FOR EXPLANATORY LANGUAGE ` APPLICATION* FORBUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS// I hereby affirm that 1 have a certificate of consent to self insure, BUIkDING ADDR SS �� /7��'• 14�� or a certificate of Workers' Compensation Insurance,or a certified ((��(/ � (�"e L copy thereof(Sec.3800,Lab.C.) CITY ZIP C LOCALITY Policy No. Company SIZE OF LOT I NO,OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified Copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. Date Applicant rDWIR RlQAP B Off( PAGE _7 PARCE,J,� �i, & �� /P— SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' TEL NO. COMPENSATION INSURANCE WITHIN loon FT.of SCHOOL? Yes No s section neenot be competed ithe permit s or one hundred ADDRESS (Thitid lif iif -5S!3 o DISTRICT GROUP TYPE CONST, FIRE ZONE PROCESSED BY dollars ($100)or less.) // _R 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 t0 CITY K� I'1+�'� )p ZIP 9/770 D n become subject to the Workers'Compensation Laws. TECT OR ENGINEER TEL NO. STATISTICAL CLASSIFICATION FST CONDO_j_to Date Applicant ADDRESS {�,,�/? CLASS NO. I'_ DWELL UNITS :2 o e"J NOTICE TO APPLICANT.' If, after making this Certificate ofkn C �� ""+ ` REQUIRED TOTAL SETBACK FROM I C-'t-'EXIST Exemption, you Should become Subject to the Workers' CON CTOR TEL NO. SET BACK YARD HWY PROP,{INE; WIDS _+ Compensation provisions of the Labor Code, you must forthwit FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL C."+ t- LICENSED CONTRACTORS DECLARATION SIDE CITY LIC.CLASS P La ?:2L I hereby affirm that I am licensed underprovisions of Chapter 9'1�1EWER MAP >- (commencing with Section 7000)of Division 3 of the Business and SQ.FT^"�/_ NO.OF STORIES NO.OF AMILIES { 111 Professions Code,and my license is in full force and effect. {{�� - �— NEW BK PG s-Iji'i !a_7 O License Number Lic.Class DESC I ON OF WORK VALUATION 00. Fy.� ••;•o— ^^ `pMai,� 5 ADD ❑ Contractor Date ` '7 ALTER ❑ $f _}s,::I O ❑ I am exempt under Sec. v REPAIR O $ I I{E P1_� U BAP.C.for this reason DEMOL ❑ LDMA P/C# !'_. = �__ _•"5 W USE OF EXISTING BLDk, Y•a•.. a Date: URM 1:1T ;•Jc-2 -_:� fn Signature ANT(PRINT) _ TEL NO. LDMA Perm# f_•i.(,=;•f = n i!_t _ I, as owner of the property, or my employees with wages as G Z their sole compensation, will do the work and the structure is ADDRES '- ^ 0 not intended Or offered for sale (Section 7044, Business an MILLNW % FINAL DATF, Q _y. Professions Code.) D �l:1sE_f^ 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 � ' v V r•�l _ Am, .:� El 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY —+--• •�• •`•'r•�a'*= licensed contractors to construct the project (Section 7044, YES❑ No❑ Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR U GUIDELINES. I hereby affirm that there is a construction lending agency for YES El No❑ w the performance of the work for which this permit is issued(Sec. ti p1 IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING / 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 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. o Lender's Address O OWNER 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 P.C.FEE PERMIT FEEiy,..� N with all county ordinances and State laws relating to building ro constr tion, arld hereby autho ize representatives of this County ISSUANCE FEE to ente up n th a ov entio ropert for inspection purposes. 1p. Q a y INVESTIGATION FEE TOTAL FEE ^ eg�am,a of ieahI AWV - SEE REVERSE FOR EXPLANATORY LANGUAGE