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HomeMy Public PortalAbout5301 ZADELL AVE_Building_2/14/1996_ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY 4-WORKER'S COMPENSATION DECLARATION FOR APPLICAWk T01-11-1-IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS �� sZ or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) CITYzIP C � 1 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 ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. a COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one dred ADDRESS DISTRICT GROUP T CONST. FIRE ZONE PROCESSED gY dollars($100)or less.) 01 CITY ZIP I certify that in the performance of the work for which i permit is issued, I shall not employ any person in any mann o as to ARCHITECT OR ENGINEERTEL NO. become subject to the Workers'COmpen tion Laws. — STATISTICAL CLASSIFICATION APT CONDO V/DateuApplicant ADDRESS CLASS NO.�L DWELL UNITS NOTICE TO APPLICANT. If after ma g this ificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should Come S fect to a Workers' CON ACTOR L NO. S BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith ,a comply with such provisions or this perm#shall be deemed revoked. ADD@9Q8_q A4 I .NO. P IL �- ' 0_ LICENSED CONTRACTORS DECLARATION cl LIC.C S PILE U I hereby affirm that I am licensed underprovisions of Chapter 8 U j 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. 6Z> f NEW 11 BK PG 00 License Number ' Lic.Class DSC IP ON OF WORK i ADD ❑ VALUATION Contracto ate ALTER ❑ $ ( � N ❑ 1 am exempt under Sec. t REPAIR ❑ $ Z BAP.C.for this reason DEMOL ❑ LDMA P/C e Date: TJSL#OF EXISTING BLDG. URM ❑ Signature APP N T) TEL NO. _ a ❑ 1, as owner the pro rty, or my loyees with wages as © k5i � Z ACCT e a their sol compens ' n, will do t work and the structure is ADDRE ,( 0 �_ o� riot inte ded or erred for sale ( action 7044, Business and 3 J FINAL DATE 3�I�a C Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL `r� J 1 ITEM$ OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ 1, as owner Of the property, am exclusively contracting 4AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES Q licensed contractors to construct the project (Section 70444,, FINAL BY , > I-I i AL226. 05 YESBusiness and Professions Code.) WILL ❑ No❑ CASH j r WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING C•ALH 72�00'� OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR CHANGE .00 GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ NO❑ the performance of the work for which this permit Is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING r 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, 0000-0001 2/14/961 TITLE 2.CHAPTER 2 20 SECTIONS 2 20 100 THRGH 2 20. Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM4O THE SCAOMD.CONCERNING HAZARDOUS u8 4865 1 Pti1?=1t, Lender's Address OWNER OR RCENT I certify that I have read this appl' Ion and state under penalty P.C.FEE A of perjury that the above inform is correct.I agree to comply PERMIT FEE / ur with all county ordinances a State laws relating to building m construction, and hereby aut ze representatives of this County ISSUANCE FEE 7,0 to enter up �aabo--menl 'ned propertyfor inspectionpurposes. INVESTIGATION FEE TOTAL FEE canl . 1C7Cq07 SEE REVERSE FOR EXPLANATORY LANGUAGE