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HomeMy Public PortalAbout4800 BALDWIN AVE_Building_4/29/1996F- '. qft APPLICATION FO:R BUILDING PERMIT m`• COUNTY OF LOS ANGELES . BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN IBu DING ADDRESS u—) I hereby affirm that I have a certificate of consent to self insure, BUI DIN G AD D ESS A` u or a certificate of Workers' Compensation surance,or a cer I x' 1" N 7 copy thereof (Sec.3_8t020 Lab.C J. O CITY P„^ C7Y 9 ZIP / 7e© LOCALITY Poli No a`5^— 9 Compan 60 V” " SIZE OF LOT NO.OF BLDGS.NOW ON LOT Certified copy is hereby furnished. I NEAREST CROSS SST. Q Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. depart USE ZONE MAP NO. Datc Applicant "' ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. y COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? YES No This section need not be completed if the permit is for one hundred ADDRESS DISTRICT'- GROUP TYPE CONST. FIRE ZONE PROCES Y dollars ($100)or less.) rt CITY ZIP 0 l y J I certify that in the performance of the work for which this permit r/(S ! 11 .. / Yisissued, I shall not employ any person in any manner'so as to L become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO. 1 P STATISTICAL CLASSIFICATION APT CO O 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' CONTPCTQR r II ll TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwithQCIUSnE o N FRONT comply with such provisions or this permit shall be deemed revoked. iD R T8 r'• LIC.y0 PL LICENSED CONTRACTORS DECLARATION rJv IC(P SIDE Q C LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP commencing with Section 70 00)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. NEW BK PGJ O License Number 61 3(0/ Lic.Class DESCRIPTION OF WORK ADD VALUATION 00,WOUACIT. n'ALTERContractJ•QDk DateOy B 7 I. c STZ.U6 O SCJ/'' 1:3 $I am exempt under Sec. REPAIR tB.BP.C. for this reason 41' 3, S t00z- DEMOL LDMA P/C.#. tIGG I,g Date: USE OF EXISTING BLDG. URM 11 77 G71— S ht!Q9 Signature APPLICANT(PRINT) TEL NO. LDMA Perm# c 22U.65 1, as owner of the property, or my employees with wages as / vv= ` 99L0023 Z 2 NEMS their sole compensation, will do the work and the structure is ADDRESS 9 11 ^• H TI=1Tt not intended or offered for sale (Section 7044, Business and S J [/, FINAL DATE C 279 - 1•5 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J CHECK 1 El I, as owner Of the property, am exclusively contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE, AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? Q t licensed contractors to construct the project (Section 7044, FINAL CHANGE f YES 1:1 NO f•-' 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 j-ILL•iGUIDELINES. ^/z J I.hereby affirm that there is a construction lending agency for YES No[fid 610 t f PM %51--:37theperformanceoftheworkforwhichthispermitisissued(Sec. HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 1V G 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. m Lender's Address OWNER OR AGENT 3 I certify that I have read this application and state under penalty 0- P.C.FEE* PERMIT FEEM.C•.J l/ r up 0 of perjury that the above information is correct.I-agree to comply J 0nwithallcountyordinancesandStatelawsrelatingtobuilding o construction, and hereby authorize representatives of this County ISSUANCE FEE O 2y 01 s to ter gon the above-mentioned property for ins pection INVESTIGATION FEE TOTAL FEE a , yoame of A.dK.,a,Awl Date SEE REVERSE FOR EXPLANATORY LANGUAGE