Loading...
HomeMy Public PortalAbout4851ALESSANDRO AVE_Building (4) f AF R- ICATION FOR BUILDING PERMIT L�J'11/�1IIIII y LI COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILJI 'ADD SS .97 Liz I hereby affirm that I have a certificate of consent to self insure, BUILDIN D ESS A910 A/O 1299 4sle' or a certificate of Workers' Compensation Insurance, or a certified copy thereof 3800,Lab.C.) _ 9 r— LOCAL( Policy No. Compan;�, SIZC OF LOT NO.OF BLDGS.NOW ON LOT I� _,EI Certified copy is hereby furnished. NEAREST CROS ST. . IV ❑ Certified copy is filed with the c y buil g inspe ion TRACT BLOCK LOT NO. de artment. - - USE ZONE MAP NO. Dat �vAPPlicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPT FROM WORKERS' o ER T N r h COMPENSATION INSURANCE 1J / WITHIN 1000 FT.OF SCHOOL? YES No This section need not be completed if the permit is for one hundred ADDRE S' ( P P � DISTRICT_ .GROUP TYPE CONST. FIRE ZONE PROCESSED BY ' dollars ($100) or less.) CITY ZIP I certify that in the performance of the work for which this permit �� is issued,'I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. become subject to the Workers'Compensation Laws. STATISTICAL CLASSIfICATION APT CONDO Date Applicant & ADDRESS CLASS NO.P2 DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become Subject t0 the Workers' CONTRACTOR Lj#f�) ^� SET BACK. YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith 6 FRONT comply with such provisions or this permit shall be deemed revoked. U A DRE,z� �1 LIC.NO. P.L LICENSED CONTRACTORS DECLARATION SIDE LI .CL $�,� P L I hereby affirm that I am licensed underprovisions of Chapter 9Im5ad4ar, ' 1. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT. Fig NO. F STORIES NO.OF FAMILIES Professions Code,and m license is in full force and effect V NEW ❑ BK PG , a- tkgG RIPATION OF WORK ADD ❑ VALUATION License Number Lia. Class ® lfl iV 4 i•o� 4 0 Contracto � ate `�' '[ Cv' ALTER ❑ (�" cc ❑ I am exempt under Sec. REPAIR BAP.C. for this reason DEMOL ❑ LDMA P/C# V W Date: USE OF EXISTING BLDG. URM ❑ 0_ Signature APPLICANT(PRINT) TEL NO. .LDMA Perm# Z ❑ I, as owner of th operty, or my employees with wages as Z s their sole com sation, will do the work and the structure is ADDRESS O p - FINAL DATE" not intended or offered for sale (Section 7044, Business and 2 Q p_� 1 _ Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL, ,©~� 7 33Vv OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL'TO OR GREATER THAN THE ❑ I, owner of the property, am exclusively contracting , AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 5 1 1 T EN ves❑' liceenn sed contractors to construct the project. (Section 704444, Business and Professions Code.) No ElT TOTAL �65 60 WILL THE NO USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH p CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR, �.Ih� � p� O(Sks ':". Li,�•: _ ia�_I? - GUIDELINES. � � _ 2Vj, _ I hereby affirm that there is a construction lending agency for YES❑ No❑ �� �.�i;ANGE X11 i �A/ �J N the performance of the work for which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097, Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, N TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS 3 Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. _ /-:n— Lender's _i o Lender's Address OWNER OR AGENT 35371 1 AM 't o LS_ o 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 P.C.FEE PERMIT FEE 1 ij - o with all county ordinances and State laws relating to building /com-^S' cD constru and hereby a horize representatives of this County ISSUANCE FEE �� ,J„ o /hhT—/ c(0o to ent u n the above- e loved proper�or insp ion purposes. INVESTIGATION FEE TOTAL FEE Sg,- of Applicant or le �J c� SEE REVERSE FOR EXPLANATORY LANGUAGE