The URL can be used to link to this page

Home My Public Portal About4833ALESSANDRO AVE_Building (3) ' APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN B ILDIG ANDD SS �� I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS or a certificate of Workers'Compensation Insurance, or a certified 4 y copy thereof (Sec.3800,Lab.C.) /mss,, ,✓ CITY_ — (/t ZIP ^7 Policy No. uI Company /ri%Lc" �� `� // LOCALITY SIZE OF LOT NO.OF BLDGS.NOW ON LOT ,,i'C.ertified Copy is hereby furnished. NEAREST CROSS ST. ❑ Certified Copy is filed with the cpunty build in nSpection TRACT BLOCK LOT N0. (J(,/(l f)' USE ZONE MAP NO. department. Date % ' - Appl.Cant ASSESSOR MAP BOOK PAGE PARCEL —� SPECIAL CONDITIONS CERTIFICATE OF EXEMPT14OTFROM WORKERS' OWNER TEL Na / COMPENSATION INSURANCE Gc Lu ./�f-1 � P Q/6J WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS � DISTRICT GROUP TYPE ON�S,Ty.� FIRE ZONE PROCE D BY dollars($100) or less.) CITY ZIP `V n �I� I certify that in the performance of the work for which this permit (YJ is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER become subject to the Workers'Compensation Laws. TEL NO. STATISTICAL CLASSIFICATION APT CO DO Date Applicant ADDRESS n pq CLASS NO, DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate Of � ,C T VD�� /V(J�� REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become Subject to the Workers' CON RACTO `�, TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith ! C, "© FRONT comply with such provisions or this permit shall be deemed revoked. AD RESS h .LI NO 3/ P L LICENSED CONTRACTORS DECLARATION01t _ IO ,: f SIDE CITY LIC.CL S P L I hereby affirm that I am licensed underprovisions of Chapter 9 A SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LCRITION NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW ❑ BK PG a License Number��%3 / Lic. Class C-S OF WORK /� ADD ❑ VALUATION , O Contractor ��/r Date/6"/ (/ JiQp�r ALTER ❑ IZR U ❑ 1 am exempt under Sec. REPAIR OO BAP.C. for this reason p/� gAl _ OL ❑ LDMA P/C# W Coe: USE OF EXISTING BLDG.' URM ❑ EL SignatureC�Ar,NT(PRIN TEL NO. /+ LDMA Perm# i z ❑ I, as owner of 7sation, perty, or my employees with wages as �/ G' N -7R2 '�t7� OZ their sole compwill do the work and the structure is ADD ESS 271- � not intended or offered for sale (Section 7044, Business and i C s `✓ FINAL DATE Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 1 3 J OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE .i J ❑ I, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 169 - 65 licensed contractors to construct the project (Section 7044, VES❑ NO 1:1 Business and Professions Code.) . �� WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING ."•[i = OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ',.`!f'=L•1`. 1i—,'°'• CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. •'_.�..'�},liy�� I hereby affirm that there is a construction lending agency for VES ElNOD N the performance of the work for which this permit is issued(Sec. O� I HAVE READ THE HAZARDOUSMATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING N 3097, Civ.C.) CHECKLIST.I UNDERSTAND MV REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. j i t j C, +s TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.740 CONCERNING HAZARDOUS i ji'III~_:•—t�I FE 1 1 ,g i; I Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. — + o Lender's Address OWNER OR AGENT o I certify that I have read this application and state under penalty O of perjury that the above information is correct. I agree t0 comply P.C.FEE PERMIT FEE with all county ordinances and State laws relating to building {r S CO cons tion, and h eby authorize representatition, and h eby authorize representatives of this County ISSUANCE FEE to a on the ab mentioned ro ert for in t' n u ses. a to / m INVESTIGATION FEE TOTAL FEE � srenzmre o1 Aa o�Agent te 1 SEE REVERSE FOR EXPLANATORY LANGUAGE