HomeMy Public PortalAbout4838ALESSANDRO AVE_Building (3) r
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS 1-0346
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I hereby affirm that I have a certificate of consent to self Insure BUILDING ADDRESS + v 4030
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or a Certificate of Workers Compensation Insurance or a certified
copy thereof(SAo
ec 380 Lab C) n�z / CRY ZIP n r� �/�
S%/r / FU/V T �i I b O v LOCALITY I G
Policy NO _7 Ompany- SIZE OF LOT NO OF BLDGS NOW ON LOT _ 1
❑ Certified copy is hereby furnishedNEAREST CROSS ST
❑ Certified copy is filed with the county building Inspection TRACT BLOCK LOT NO
department /1 ` USE ZONE MAP No
Date Q�/0 Applicant /f` /7y r//VD ASSESSOR MAP BOOK - PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS OWNER TEL NO
COMPENSATION INSURANCE Z-IlllkcI-yert-snIo-L"� WITHIN 1000 FT OF SCHOOL? ves No
(This section need not be completed If the permit is for one hundred ADDRESS
dollars($100)Or less) D LA- e DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
I certify that In the performance of the work for which this permit CITY`✓� ZIP t ^ ^A L 0
8 R_,5
is Issued I shall not employ any person In any manner so as to F L �(j
become subject to the Workers Compensation Laws ARCHITECT OR ENGINEER TEL NO
STATISTICAL CIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO DWELL UNITS
NOTICE TO APPLICANT If after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption you Should become subject to the Workers CONTRAC�T R TEL NO t� SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Coder you must forthwith .S V cD 46 or loksA, 0 1 5' t FRONT
comply with such provisions or this permit shall be deemed revoked ADDREE�S((S// LIC NO _ P L
J7-j- 5 79 SIDE
LICENSED CONTRACTORS DECLARATION CITY 1 r LIC CAS PL
I hereby affirm that I am licensed underprovlsions of Chapter 9 t SEWER MAP i
(commencing with Section 7000)of Division 3 of the Business and SQ FT SIZE NO OF STORIES I NO OF FAMILIES
Professions Code and my license is in iull force and effect ` NEW 1:1BK PG
/� d
License Number r of s73 LIC Class ` DESCRIPTION OF WOrr-ORK , ADD ❑ VALUATION O
Contractor S ^ Date I Q^/(o�S " ory.I 60M a ALTER ❑ $ 00 7 V
acc
S/(/ S elf-OAC-LtRoM REPAIR 0
El am exempt under Sec \
B&PC for this reason e MU
EOL ❑ LDMA P/C# A III
C)
Date USE OF EXISTING BLDG URM ❑ 1 Ca/-
Signature ' APPLICAN (PRINT) ' �! T NO LDMA Perm# 1 Z_
El as owner of the property or my employees with wages as L- W s Z rn t T e g
their sole compensation will do the work and the structure Is
ADDRE 17 2
not Intended or offered for sale (Section 7044 Business and IS ��F�lJN � ��'} OrXt?t7ij 21 FINAL ID ProfessionsT�\E ��� J o.3303 116.99
PfOfeSSIOS Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL (( 1 ITEMS
El OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
licI as owner of the property am exclusively contracting 44 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY
Bu
n Contractors to construct the project (Section 7044 YES El NO 9� TOTAL i-16 m 99
Busineess s and Professions Code) ,
WILL THE INTE (HECK 1 6097
NDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ( ,a
CONSTRUCTION LENDING AGENCY COAST AIR QUA��EMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR ((JJ�k'/j'' (('yy
GUIDELINES CHMIGE 1 .00
I hereby affirm that there is a construction lending agency for YES❑ NO - A
w the performance of the work for which this permit is Issued(Sec ('► (]
N 3097 CIV C) I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING M-0001 10I16I9`
CHECKLIST I UNDERSTAND M REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE
TITLE 2 CHAP T 0 SEC NS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS
Lenders Name MATERIAL! R G A T N P MIT FROM THE SCAQMD
0 Lenders Address _ 2804 1 AM 7 J4
0 OWNER OR AGENT
I certify that I have read this application and state under penalty
0 of perjury that the above Information is correct I agree to comply PC FEE PERMIT FEE r-)
with all county ordinances and State laws relating to building
m construction and hereby authorize representatives of this County ISSUANCE FEE
to enter n h a e mentioned property for Inspection purposes 2
a
INVESTIGATION FEE TOTAL FEE
SV i I Apue I o Aa I D
SEE REVERSE FOR EXPLANATORY LANGUAGE