HomeMy Public PortalAbout4803ALESSANDRO AVE_Building (3) APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that 1 have a certificate of consent to self insure, BUILDING ADDRESS
or a certificate of Workers`•Compensation Insurance, or a certified
copy thereof�(Sec.3800,Lab.C.) CI Y ZIP /�J
Policy No. P � p1/ G'n/'1 jfi —c / / LOCALITY
T,—,—�., /��,Company SIZE F LIZ, NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. c, ,1� NEAREST CROSS ST.
❑ Certified copy is filed.with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
Date;"�Applic �'' - �-- ASSESSOR MAP BOOK PAGE PARCEL A
/J / SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER / No.
COMPENSATION INSURANCE 13
WITHIN 1000 FT OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred AL}DRESS
DISTRICTGROUP- TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100)or less.)
C ZIP
I certify that in the performance of the work for which this permit �. . j C�/71 �� -
is issued, I shall not employ any person.in any manner so as to ARCHITECT R ENGINEER / TEL NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS - CLASS NO. 4:<?-// DWELL UNITS
NOTICE TO APPLICANT.' If, after, making this Certificate ofREQUIRED TOTAL SETBACK FROM EXIST
Exemption,/"You? Should become Subject to the Workers' CONTRACTOR TEL N 0 SET BACK YARD HWY PROP LINE WIDTH
Compensation provjsions of the Labor Code, you must forthwith G afi FRONT
comply with such provisions or this permit shall be deemed revoked. A DDR g LI NQ— PL
LICENSED CONTRACTORS DECLARATION Cb SIDE
CIZY' LJ Gj LI CLASS P L
I herebyraffirm that I am licensed underprovisions of Chapter 9 �G �T /�G " C 3_—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
License Number65�77 C4-4 Lic. Class /C�_� DESCRIPTION OF WORK y / App EJ d
Contractor2,ST�r�C Date o1j / ` O
cc
11AIP 1,,W1,1
ato REPAIR ❑ `y
I am exempt under Sec. $ R
---' �^
El0
i i d .
BAP.C.for this reason SQDEMOL ElLDMA P/C# V
LU
ate: USE OF EXISTING BLDG. URM ❑ •s
Signature ���'�-' iti Ica _ Z
APPLICANT(PRINT) TEL NO. LDMA Perm# "
❑ I, as owner of the property, or my employees with wages as ^yl
Z i`tita.��
their sole compensation, will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DAT17 a0010- TQ
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL l , 31
J •'_AI- 214 .
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE V r;.
El 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIE N THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL CHECK
licensed contractors to construct the project (Section 7044, YES❑ No
is4a_�
Business and Professions Code.) CHANGE
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING a I ij�j
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. ' �-,/
I hereby affirm that there is a construction lending agency for YES 11 NO�a }� T _
>..r.E i0r� {�e
N the performance Of the Work for which this permit IS Issued(.Sec. (HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING q:
?o i
N3097, Civ:C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THELO ANGELES COUNTY CODE, i•.'{'f 3 f a i f
TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20. CONCERNING HAZARDOUS
Lender's Name MATERIALS RE
o �BTAIN �AT P THE SCAQMD.
Lender's Address _
O OWNER OR AGENT
o {' I certify that I have read this application and state under penalty
C)Jm'
, of perjury that the above information is correct.I agree to comply P.C.FEE n ®,/O PERMIT FEE ,
with all county ordinances and State laws relating to building
construction, and hereby authorize representatives of this County ISSUANCE FEE
to ent pro ty ion purposes. INVESTIGATION FEE TOTAL FEE
nature of Applicant or Agent Date 7
SEE REVERSE FOR EXPLANATORY LANGUAGE