HomeMy Public PortalAbout6131 AVON AVE_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS �g lu 4v��
I hereby affirm that I have a certificate of consent to self insure, BUILDIN AD q)<SS
or a certificate of Workers' Compensation Insurance,or a certified ( -7 �-'
copy thereof Seo 3$ CJ CITY
ZIP
Nl LOCALITY
Policy No. `i Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. I NEAREST CROSS ST.
Certified copy is filed with the county building inspeion TRACT BLOCK LOT NO.
department. , USE ZONE MAP NO.
1�+Jd ASSESSOR MAP BOOK PAGE PARCEL
Date ApplicagL SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER,- a TEL NO. !O
Nper
SATION INSURANCE �(� WITHIN 1000 FT OF SCHOOL? Yes No
(This section neompleted if the permit is for one hundred ADD SS i I - 1
dollars ($100) V N P� DISTRICT GROUP TY,F CONST. FIRE ZONE PROCESSED BY
CITY ZIPI certify that in mance of the work for which this permit � ais issued, I shaloy any person in any manner so as to ARCHITECT OR ENGINEER TEL NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION 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 to the Workers' COI`4 CTOR ( ` T SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith ��VJ - L(C lJ
FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS . P L
LICENSED CONTRACTORS DECLARATION cc SIDE
CITY � _ LI AS3 2 PL
I hereby affirm that I am licensed underprovisions of Chapter 9 J SEWER MAP >-
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES d
Professions Code,a_my lice is in full force and effec NEW ❑ BK PG
License Nu er � Lic.Class C-3 DESCRIPTION OF WORK ADD ❑ VALUA ION _ �
CD
Contractor Date 30 s ALTER ❑ $ v
W
O CL
I am exempt under Sec. REPAIR El
B.BP.C.for this reason ,� DEMOL ❑ LDMA P/C#
Date: USE OF EXISTING BLXX., URM ❑
Signature _ qpp fcpNr� T NO. /'�y LDMA Perm# s
❑ I,as owner of the property, or my employees with wages as tY%t�/'J 7 `"CJ 0 T"$
their sole compensation, will do the work and the structure is ADDR S '`' _
not intended or offered for sale (Section 7044, Business and ���� FINAL DATE
Professions Code.)
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
❑ 1, as owner of the property, am exclusive) contractingwith OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ✓✓✓ r
y AMOUNTS SPE FIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY y + {•'W
licensed contractors to construct the project (Section 7044,
Business and Professions Code.) YES❑ No a ..k
WILL THE INTENDE USE-OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING " - :••r'
OCCUPANT REQUIRE PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ±� _: ?;'-7
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❑ NO
N the performance of the work for which this permit is issued(Sec.
p+ I HAVE READ THE HA)RDOUSMATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
3097,CIV.C.) CHECKLIST.I UNDER REOUIREM 7S UNDER THE LOS ANGELES COUNTY CODE,TITLE 2.CHAPTER 2NS 2.20. 0 THROUG .20.140 CONCERNING HAZARDOUS ' (Lender's Name MATERIALS REPORTIOR OBT ING PERMIT FR' CAQMD. 'it?, - +{`•=t
o Lender's Address �7=- "`°5`
ONNER OR AGENT _F r.7 f 7 Ali
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 FEE
N with all county ordinances and State laws relating to building oc
< cos on, and here y uthorize representatives of Co my ISSUANCE FEE j �j,�
ato nt u abov -mentioned property for irisp tlo urp (y440
f j INVESTIGATION FEE TOTAL FEE
Sg_r, ,ApPI c_or Agent Gate
SEE REVERSE FOR EXPLANATORY LANGUAGE