HomeMy Public PortalAbout5933 AVON AVE_Building_5/19/1995_enclose existing patio _APPL�PAMON FOR. B_U,�LMNG PERNT
COUNTY OF LOS ANGELES P
BUILDING AND SAFETY
o r FOR APPLICANT TO FILL IN BUILDING ADDRES
WORKER'S COMPENSATION DECLARATION �
- - " -
Ihereby affirm that I have a certificate of consent to self BUILD43 ADDRESS insure, ,� � I / 7.
or a certificate of Workers' Compensation Insurance,-or a certified
-copy thereof (Sec.3800, Lab.C.) CITY ZIP
S
Alie "�7 t''� LOCALITY - -
Policy NO: Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT '
El,Certified copy is hereby furnished.' J L)4 ).10 NEAREST CROSS ST.
❑ Certified Copy is filed with the county building inspection TRACT BLOCK LOT NO. -
department. - - - USE ZONE MAP NO. -
Date ApplicantASSESSOR MAP BOOK •• PAGE PARCEL ,
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS" OWNER. L TEL NO. „
COMPENSATION INSURANCE mz4 Imes C�14aE5, )WC WITHIN 1000 FT:OF SCHOOL? YES NO
S
(This section need not be completed if the permit is for one hundred ADDRESS Gf?> ���Ave— 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 Ce �!, ZIP ,71� ��
is issued, I shall not employ any person in any manner so as to �J �! 5'1 -i v.-J
become subject to the Workers'C m ensation Laws. ARCHITECT OR ENGINEER TEL NO. V
p - STATISTICAL CLASSIFICATION APf CONDO
Mts.,'Ir >= CLASS NO. DWELL UNITS
Date 4 � g7 Applicant • K tAt��D�D�RrrE((S�bS �w /�
NOTICE TO APPLICANT.•• If, after'making this C irate Of 8659. iSS�w✓A-- 1, . `7 17-7 0 REQUIRED TOTAL SETBACK FROM EXIST.
Exemption, you . Should become Subject t0 the' Workers' C NTRACTOR- TEL NO. SET BACK YARD . HWY PROP LINE WIDTH
Compensation provisions of.the'Labor Code,.you must forthwith PAWeA0 -436(n FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P IL
LICENSED CONTRACTORS DECLARATIONZOO.. SIDE
CITY LIC.CLASS. P IL
I"hereby affirm that I am licensed underprovisions,of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SO.r FT.SIZE NO,OF STORIES NO.OF FAMILIES
Professions Code,and my I'cense is in full force and effect. /�U^• NEW ❑ BK PG d
License Number Li'.Class B-' DESCRIPTION OF WORK ADD VALUATION D O
Contractor&k�Wd�w�1
• �i 'Date S'Zv�iS
ALTER ElnO o . U
. . pini,ye /�- r7EnJ �
El 1.am exempt under Sec. REPAIR ❑
BAP.C.for this reason DEMOL " ❑ LDMA Pic# W
Date: USE OF.EXI INING BLDG.
DG. URM ❑ - a
Si9 nature _ AP LICANT(PRI% ) TEL NO. LDMA Perm#
ssr /3i�da'S f i�-3vls-� . ,
El 1, as owner of the property,,or my employees with wages as' • >(0 ZO
their,sole compensation, will do.the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and 2W 26261 PINAL'DATE Q `•i{ _=
Professions Code.) _ _ s
WILL THE OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J •f i o i
A MIXTUREEl 1, as owner Df the property, am exclusively contracting With AOMOUNTS SPEC FOED ON I THE HAZARDOUSSMATERAILS NOFORMATOONRGU DE?ER THAN THE FINAL BY
licensed contractors to construct the project (Section 7044, T""ri=
Business and Professions Code.) ves E3 No €
_ WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING +'^o ••EI
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH I"I4-L �7-� rs'9 .3L.
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR __
GUIDELINES. - ("4 73 L••�
.: of '2 c i E
1.hereby affirm that there is a construction lending agency for YES❑ No
a the performance of the work for which this permit is issued(Sec. f"I Wi
rn - _ (HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING - � �•i'�.Y'•'+.1= v00
3097, CIV.C.) CHECKLIST,I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
N TITLE 2.rHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS "
Lender's Name MATE S RE RTIN ND FO OBT NTNG A PERMIT FROM THE SCAQMD.
o Lender95
0. 's Address i€1 �_� U;S.L 1 -
0 OWNER OR AGENT ,
o I certify that I have read this application and state under penalty n-+ Y.; :q
o P.C.FEE PERMIT FEE U4. int 3 _
of perjury that the above information is correct. I agree to comply r
with all county ordinances and State laws relating to building
OD con truct'on' and hereby authorize representatives of this County ISSUANCE FEE_
ID
0 to ter Upon the ab ve mentioned property for inspection purposes.
m ?� �C�� INVESTIGATION FEE - TOTAL FEE
SgnaWre of Applicant or Agenl Date '
SEE REVERSE FOR EXPLANATORY LANGUAGE