HomeMy Public PortalAbout5947 AVON AVE_Building_3/1/1995_enclosed patio and open patio APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES • BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUI N�glDpR Ss ,/��
I.hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESSkil� G�,L/ 4 Y
or a certificate of Workers' Compensation Insurance,or a certified b q
copy thereof (Sec.3800,Lab.C.) CITY // J/ ZIP t -
�" 6•j lOY`GT.�. ( Co,, l �'Z '7J LOCACZ
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. - '2— 'NEAREST CROS ST. -
❑ Certified copy is filed with the county building inspection TRACT BLOCK - LOT NO.
department. USE ZONE -MAP NO.
Date _ Applicant
ASSESSOR MAP BOOK�0 PAGE r/2 PARCEL ,,,
Jr
O A SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER / TEL No. -
COMPENSATION INSURANCE % t � WITHIN 1000 FT.OF SCHOOL? YES No
(This section need not be completed if the permit is for one hundred ADDRESS
•� V 31q � DISTRICT GROUP TYPE CONST. FIRE ZONE - PROCESSED BY
dollars ($100)or less.)
I certify that in the performance of the work for which this permit CITY �,fre-C. ZIP /�
is issued, I shall not employ any person in any manner so as to SS
become subject to the Workers'Compensation Laws. - ARCHITECT OR ENGINEER TEL NO.
P STATISTICAL CL.A�$}SIF/IC�ATION APT CONDO
Date Applicant ADDRESS CLASS NO. rL� DWELL UNITS
NOTICE TO APPLICANT.' If, after making this Certificateof REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTORTEL 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. P L
LICENSED CONTRACTORS DECLARATION PILE
CITY LIC.CLASS P L
I hereby affirm that I am licensed underprovisions of Chapter 9 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. NEW ❑ BK PG a
License Number Lic.Class DESCRIPTION OF WORK ^�� ADD ❑. VALUATION Cl - Q
$ 7S-90-- f�_ _ . =Ir v
Contractor Date , ALTER ❑
ElI am exempt under Sec. Cl-JATi f`G �� REPAIR ❑ $ -
B.&P.C.for this reason DEMOL ❑ LDMA P/C# Ill
Date: USE OF EXISTING BLDG. URM ❑ + ti• •�- 11
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Signature APPLICANT(PRINT)
❑ I, as owner of the property, or`my employees with wages as 1 ' � ! A
their sole compensation, will do the work and the structure is. ADDRESO
� / / +
not intended or offered for sale (Section 7044,Business and �/U✓► �' �f 0/1�78^trk= FINAL DATE Q €,f;8_ a �-,
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 3"• J S Ems'�•�' LL's= ,
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE '�-+:i .. r-._
❑ I, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY W
licensed contractors to construct the project (Section 7044,
Business and Professions Code.) YES El No❑ `+:1 J�•
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 QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES. 's=j);fit—{}3 iFi',, _r•
I hereby affirm that,there is a construction lending agency for YES❑ NO❑ Iz
w the performance of the work for which this permit is issued(Sec.
m I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD 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 SCAQMD.
m Lender's Address
O OWNER OR AGENT "
o I certify that I have read this application and state under penalty
O of perjury that the above information is correct.I agree to comply P.C.FEE q� PERMIT F6 so
F.E�
with all county ordinances and State laws relating to building v
m construction, and hereby authorize representatives of this County ISSUANCE F.s�r
(0 to upon the b re-mentioned roperty for inspection purposes. �.(O
a Cc'
J INVESTIGATION FEE TL EE
'cneiure�O'Hotta Agee
SEE REVERSE FOR EXPLANATORY LANGUAGE