HomeMy Public PortalAbout5420 ACACIA ST_Building_11/9/1992_Add 840 sf living space 420 sf garage APPLICATION FOR BUILDING PERMIT v
' COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING ADDRESS
WORKER'S COMPENSATION DECLARATION
BUILDING ADDRESS � '�—�
I hereby affirm that I have a certificate of consent to self insure, #p DD ACI
or a certificate of Workers'Compensation Insurance,or a certified "^^"TT p
copy thereof(Sec.3800,Lab.C.) �`���s LOCALITY
Policy No. Company
SIZE OF LOT 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.
ASSESS O M B PA PARC
Date Applicant SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNE 4�/ .,_, YES NO
COMPENSATION INSURANCE ADDRESS WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.) h Z
I certify that in the performance of the work for which this permit � C //77 6, �/+
is issued, I shall not employ any person in any manner so as to rARCHITCTO ENGI EER TEL.N `, � l�become subject to the Workers'Compensation Laws. c, � L � STATISTICAL CLASSIFICATION APT CONDO
Date Applicant v CLASS NO. DWELL UNITS
NOTICE TO APPLICANT. If, after makin this Certificate of �� 'g � � � REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CTOR / 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 }
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS p L a
0
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP U
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORES NO.OF FAMILIES OC
Professions Code,and my license is in full force and effect. 2-- NEW ❑ BK PG , �
DESC IPTION OF WORKADD VALUATION W
License Number Lic.Class �(.% fit" S �' U-
Contractor Date r ALTER $ _Z
❑ I am exempt under Sec. " f S v E REPAIR ❑ $
Z t 4
B.BP.C.for this reason V DEMOL E3LDMA P/C#
Date: USE OF EXISTING BLDG. URM ❑
i
Signature APPL CANT(PRINT) TEL.NO. LOMA Perm#
I it/V 7"Z�9 � '6a3a Z AC-C.T.
1, as owner of the property, or my employees with wages as p _ �r Y�
their sole compensation, will do the work and the structure is ADDRESS
P F r �.��1.''_7
not intended or offered for sale (Section 7044, Business and FINAL DATE C �'
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN J
❑ 1, as owner of the property, am exclusively contractingWith THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BYH".1T a
licensed contractors to construct the project (Section 7044, YES❑ ❑
NO
Business and Professions Code.) _307 JJ175,t,4
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 1.T "j�•
CONSTRUCTION LENDING AGENCY
�1�CONSTRUCTION LENDING AGENCY h l COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST y 1 ii
FOR GUIDELINES.
I hereby affirm that there is a construction lending agency for .� YES❑ NO❑ TOTAL
l
3C4eCz,�
the performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMOL{��[JJ j 1 iz f'
3097,Civ.C.). �� PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES i•i-iG1.•! iv.''i■_':
m COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING
i3 Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. r,j•{ANGECL IJf 1
3
CL Lenders Address G ER GR AGENT
o I certify that I have read this application and state that the above RC.FEE PERMIT FEE _ 1' J " '{
information is correct. I agree to comply with all county ref. •I / n� OG� 's i3jE�( i;lalf `
ordinances and State laws relating to building construction,and ✓ L' L
a hereby authorize rfrersi tatives of this County to enter upon G ISSUANCE FE ti�?'f i AM 7 Q >
the ab e-mentiona ty for inspectiu� -C,�, -INVESTIGATION FEE TOTAL FEE
Sprat-of Applkanl or AysH D.Os
SEE REVERSE FOR EXPLANATORY LANGUAGE