HomeMy Public PortalAbout4926ALESSANDRO AVE_Building (3) APPLICATION FOR 46ILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING A S$L4
I hereby affirm that I have a certificate of consent to self insure, BUILD PRESS �r
or a certificate of Workers' Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) CIT r [ ZIP
L el T LOCALITY / A
Policy No. Company _v
SIZE OF LOT / NO.OF BLDGSON LOT
❑ Certified copy is hereby furnished. _Ir ff . W/ NEAREST CROSS Sj. 6,e
❑ Certified copy is filed with the county building inspection TRACT. BLOCK LOT NO. L��(/
department. 1 USE ZONE MAP NO. .
Date Applicant
ASSESSOR MAP BOOK PAGE PARCEL50
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWU� �^ EL o.
COMPENSATION INSURANCE (• ' WITHIN 1000 FT OF SCHOOL? Yes No
NE
(This section need not be completed if the permit is for one hundred ADDRESS /L
�J DISTRICT GROUP TYPE CONST. FIRE ZONE PROCES B
dollars ($100)or less.)
I cer CITY ZIP [`-D
y that in the performance of the work for which this permit J
/Da
ed, Ishall not employ any p rson in any ma r so as toome subject to the Workers' mpenS n w . ARCHITECT OR ENGINEER TEL NO. STATISTICAL CLASSIFICATION APT CO 0e/"� AppliC t ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT.• If, afte making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become Subject t0 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. E NO.OF STORIES NO.OFfAMILIES },
Professions Code,and my license is in full force and effect. NEW BK PG a
DESCRIPTION W RK VALUATION , O
License Number Lic.Class ADD ❑
cc
Contractor Date ALTER ❑
❑ I am exempt under Sec. REPAIR ❑ $ 0
B.&P.C. for this reason DEMOL ❑ LDMA P/C# d
Date: USE OF EXISTING BLDG. URM ❑
Si nature APPLICANT(PRINT) TEL NO. LDMA Perm# 1
ty1 I, as owner of the property, or my employees with wages as ZO ACCLAT
their sole compensation, will do the work and the structure is ADDRESS ,� n
not intended or offered for sale (Section 7044, Business and FINAL DATE n Q �03 10U.9Q
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL �� L�4 1 ITEMS
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
❑ 1, as owner of the property, am exclusively contracting with Q
project
( AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY > TOTAL :.08 m 90
licensed contractors to construct the ro'ect Section 7044, ves❑ No❑
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUICHECK BTI THE APPLICANT OR FUTURE BUILDING iV(�Oe0
/9�+
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR /^ (y
GUIDELINES. CHANGE .00
I hereby affirm that there is a construction lending agency for YES❑ No❑
w the performance of the work for which this permit is issued(Sec. (�j C}
rn I HAVE CHECKLIST.
I HE UNDERSTAND MY
INFORMATION GUIDE AND THE SC S MD COUNTYITTING V�-0001 ilJ/ 1//
3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIgEMENTS UNDER THE LOS ANGELES COUNTY CODE, i.ry
TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS
3 Lender's Name 95
MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 7902 1 AM9'33 a�;
o Lender's Address �/a
O 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 �� �O
with al county ordinances and State laws relating to building
consu tion, and hereby authod a representatives of this County ISSUANCE FEE
to e to upon the ab entio d proper Ior inspection pu loges. °
{// '�, !'' INVESTIGATION FEE TOTAL FEE
Signal a of Applicant Ag I O 0
SEE REVERSE FOR EXPLANATORY LANGUAGE