HomeMy Public PortalAbout9014 ACASO DR_Building_7/3/1990_add bathroom APPLICATION FORBUILDING PERMIT
COUNTY OF.LOS ANGELES - BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING ADDRESS
WORKER'S COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self Insure,
FNG ADDRESS
or a certificate of Workers'Compensation Insurance,or a certified 4- P.R �'�' CAS O
copy thereof(Sec.3800,Lab C) •T�N IKP4 UT 71LocAu � -
-
—Policy NO Company l T)• SIZE OF LOT NO OF BLDGS NOW ON LOT 7/2
❑ Certified copy Is hereby furnished. Z�6 �N NEAREST CROSS ST
❑ Certified copy Is filed with the county building Inspection TAT BLOCK LOT NO `
'department C J�p USE ZONE MAP NO +
Iicant �6 1•t IVYi..tl.� � ASSESSOR MAP BOOK PAGE PARCEL
Date �
-f-'-APP 7 � � � �Z p f6 SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' W0� L`f
WITHIN 1000 FT OF SCHOOLS YES NO
COMPENSATION INSURANCE
ADDRESS '
1.
(This section need not be completed if the permit Is for one hundred 75.7 Z DISTRICT GROUP TYPE CONST' FIRE ZONE 17E Y
dollars($100)or less)
I certify that.in the performance of the work for which this permit CITE• '!MW C74MI ,L ZIP 1q/770. �`•'./�(/' Jt
is Issued.-I shall not employ any person In any manner so as to ARCHITECT OR ENGINEER TEL NO UIl/I ,,,,,,///
become subject to the ftrkere'Compensation Laws STATISTICAL CLASSIFICATION APT CO
Date � Applicant ADDRESS CLASS NO DWELL UNITS
NOTICE TO APPLICANT'If, after making this Certificate of REQUIRED TOTAL SETBACK FROM, EXIST
Exemption, I CONTRACTOR TEL NO
p you should become subject t0 the Workers' � SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions'of•the Labor Code,you must forthwith Ti*A-AI '1` o mm =61—05 FRONT
comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO
42 B -so co a 6- *v 5x Z, SIDE
LICENSED CONTRACTORS DECLARATION CITY LIC CLASS PL
1 hereby affirm that I am licensed under provisions of Chapter 9 +41_H4M/jA4- SEWER MAP
(commencing with Section,7000)of Division 3 of the Business and SO FT SIZE NO OF STORES NO OF FAMILIES
Professions Gide,and my license Is in full force and effect ( 4j 0V 44 eq_- NEW ❑ BK PG
License Number 2 LID Class g •• DESCRIPTION O RK ADD VALUATION , W
Contractor Date T�9 D • D gAALTER ❑ J��� a Z
❑ 1 am exempt under Sec REPAIR ❑ $
B&PC for this reason DEMOL ❑
LDMA P/C
Date T��O _ USE OF EXISTING BLDG URM ❑ #
Signature --1 - APPLICANT(PRINT) TEL NO LDMA Perm#
❑ I, as-owner of the•property,,or my,employees with wages as 7 d6! HG A*f 1 20!?-. z
F
their sole compensation,will do the work and the structure Is
not Intended or offered for sale (Section 70 , Business and ADDRESS
44Co. Ca P_ iS *V e- n L r• FINAL DATE AC`! `g
Professions Code) 7—9 Z)
Ir(
WILLTHE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL
❑ I, 8s owner of the property; am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN .
P Y 9 THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 1 ITEMS
busied and
to construct the project (Section 7044, �J'� 00
Business and Professions Code) vEs❑ No❑ '_ ,�L 0 ;9n] .�.O.�AL ate.._
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
CONSTRUCTION LENDING AGENCY CCOAST�AIIRR REQUIRE
U LIITYAMAANAGEEMEENTT T FOR CONSTRUCTION DISTRICT SAOMD)MODIFICATION
PPETnMITnNG THESOUTH • t 82.I I11
FOR GUIDELINES
I hereby affirm that there is a construction lending-agency for
YES
❑ NO❑ CHANIGI ■130
the performance of the work for which this permit is issued(Sec I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD
3097,CIV C) PERMITTING CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES
COUNTY CODE,TITLE Z CHAPTER 220 SECTIONS 2 20 100 THROUGH 220140 CONCERNING
A — 7/" r`9�I
Lenders Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD
L Lenders Address OMER r 1636 v 1
o' 1 certify that I have read this application and state that the above PC FEE PERMIT FEE
Information Is correct I agree to comply with all county /� f1
ordinances and State laws relating to building construction,and V V�
hereby authorize representatives of this County to enter upon ISSUANCE FEE /3 Q (/
the above-mentioned property for inspection purposes. /
m 7/al fin ' INVESTIGATION FEE TOTAL FEE
8%pwAmct App wApra r I •
SEE REVERSE FOR EXPLANATORY LANGUAGE