HomeMy Public PortalAbout4802 ALESSANDRO AVE_Building_10/15/1993_reroof APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDI D0`ESS t�
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRES 802- [�rev�w��^ ♦. to; D0,(
or a certificate of Workers' Compensation Insurance,or a certified ,J� �y V
copy thereof (Sec.3800,Lab.C.) CITY ,PLe C.T" PIP � 011'7,60
vpn., T LOCALIT
Policy No. Company- SIZE OF LCT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CROSS SIF
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
USE ZONE MAP NO.
department.
Date Applicant AS MAP BOOK PAGE' PARCEL ""
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER��� �
WITHIN 1000 FT.OF SCHOOL?
This section need not be completed if the permit is for one hundredN
. ADDRESS DISTRICT GROUP TYP CONST. FIRE ZONE PROCESSED BY
dollars ($100) or less.) JA
CITY, ZIP / p� //
I certify that the performance of the work for which this permit 51A- �J1 / //-
is issued, I shall not employ any person in any manner so as to (/ /�
become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO.
STATISTICAL CL'A IFICATION APT CONDO
Date Applicant ADDRESS CLASS NC. � DWELL UNIT
NOTICE TO APPLICANT. If, after, making this Certificate of REQUIRED 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. P L
LICENSED CONTRACTORS DECLARATION SIDE
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 1 NO.OF STORIES NO.OF FAMILIES a
Professions Code,and my license is in full force and effect. Q(� W NEW BK PGPoo. Q
/,ADD ❑
License Number Lic.Class
DE CRIPTION OF WORK - VALUATION V
Rintp � pb �
Contractor Date ALTER ❑ W
❑ 1 am exempt under Sec. REPAIR ❑ $ U
B.BP.C.for this reason DEMOL. ❑ W
LDMA Pic#
CL
Date: USE OF EXISTING BLgr,
f� / URM ❑
Signature APPLICANT(PRINT) TEL NO. LDMA Perm#
I, as owner of the property, or my employees with wages as eAVw v�/�°V
their sole compensation, will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DATE Q _ �
Professions Code.) � TOTAL AL :10 e � 0
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE �.. Q e -.} a -�• ---
❑ 1, as Owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY CHECK i 1�__' {`I'
CF.>_" '
licensed contractors to construct the project (Section 7044, YES❑ NO❑
Business and Professions Code.) C i-t!NG-LE n:I:S
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. y
I hereby affirm that there is'a construction lending agency for YES El No ElG o 1-1l°3 is j`s�-I 17;!
rn the performance Of the work for which this permit Is Issued(Sec. (HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 9��.+ ' ,pfi'�}''4 'c..°' r"
3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, i a.J s t'9:} n i?
TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS
3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
0 Lender's Address
0 OWNER OR AGENT
o I certify that I have read,this application and state under penalty
of perjury that the above information is correct. I agree to comply P.C.FEE PERMIT FEE -2 P
�}
with all county ordinances and State laws relating to building C/
construction, and hereby.authorize representatives of this County ISSUANCE FEE
co
ID to enter u on the above-mentioned roperty for inspection purposes.
to '3
INVESTIGATION FEE TOTAL FEE
69nature of pli—t or Agent Date
SEE REVERSE FOR EXPLANATORY LANGUAGE