HomeMy Public PortalAbout5329 ZADELL AVE_Building_3/20/1996_ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES yX BUILDINdAND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN -)DR
I hereby affirm that I have a certificate of consent to self insure, BUILDING JIDDAESS
or a certificate of Workers'Compensation Insurance,or a cert6ied
copy thereof(Sec.3800,Lab.C.) CITY ZIP i
Policy No. Company l� r q 1 9j0 LOCALITY
IZE OF LNO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. 2. /
NEAREST CROSS
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP NO
P
Date Applicant ASSESSOR MAP BOOK AGE PARCEL e
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OHNE
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 PROCESSED 13Ydollars($100)or less.)
I certify that in the performance of the work for which this permit CITY ZIP
a D _ j
is issued, I Shall not employ any person in any manner 50 as t0 ARCHITECT OR ENGINEE TEL O. ,*� GAG
become subject to the Workers'Compensation Laws. //✓ TATISTICAL CLASSIFICATION APT CONDO
L � w/
Date Applicant ADDRESS
�� ) J /�� / CLASS NO —� DWELL UNITS
NOTICE TO APPLICANT If, after making this Certificate Of VLi �`��i7 / G. flEOUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL >-
SIDE a"
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PL V
1 hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. NEW ❑ BK PG 00
License Number Lic.Class DESCRIPTION OF WORK ADD VALUATION , U
LLI
Contractor Date AQVITI /2' _ u5 ^ ALTER ❑ $ '41bob 0-
❑ I am exempt under Sec.
REPAIR ❑ Z
B.BP.C.for this reason DEMOL ❑ LDMA PIC#
Date: USE OF EXISTING BLDG. URM ❑ 23
Signature APPLICANT(PAINT) IVY E TEL NO. / LDMA Perm r �+ TeT
1:1I, as owner of the property, or my employees with wages as IVY "� v 6P zz-LZ �j ��a 5-0�
their sole compensation, will do the work and the structure is IBES
riot intended or offered for sale (Section 7044, Business and FINAL DATE Q0. 1
Professions Code.) WALL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL �`�/7• / J
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q ACCT oa
L
❑ 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDEI FINAL BY /
licensed contractors to Construct the project (Section 7044, ,YES 11NO❑ � ! 3303 209.25
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING ITEMS
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR /�
GUIDELINES TOTAL 259 -75
1 hereby affirm that there is a construction lending agency for YES❑ NO❑ CHECK
(� /!P C-1 C
the performance of the work for Which this permit Is issued(Sec. IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMDPERMITTING CHECK 2_ly u75
3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, CHANGE
W
TITLE 2.CHAPTER 2 20 SECTIONS 2 20.100 THROUGH 2 20.140 CONCERNING HAZARDOUS CHAIN VE n 013
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
Lender's Address
OWNER OR AGENT
3r I certify that I have read this application and state under penalty 0000-000 1 3/20/96
0 of perjury that the above information is correct.I agree to comply F.C.FEE /,-� PERMIT FEE , o_O
ur with all county ordinances and State laws relating to building / S4 06 1 AM 11'08
M construction, and hereby authorize representatives of this County ISSUANCE FEEQ
0 to enter upon the above-m ntioned property for inspection purposes.
- INVESTIGATION FEE TOTAL FEE
N • M m
SEE REVERSE FOR EXPLANATORY LANGUAGE