HomeMy Public PortalAbout5019ALESSANDRO AVE_Building (3) .AP.PLICATION FOR BUILDING PERMIT �1
COUNTY OF LOS ANGELES BUILDING AND SAFETY
rFOR APPLICANT TO FILL IN BUILDING ADDRESS
WORKER'S COMPENSATION DECLARATION'
BUILDING AD RESS
I hereby affirm that I have a certificate of consent to self insure,
orPaycertifica(of Workers'Compensation Insurance,or a certified CI �� L ZIP
co thereof Sec.3800,Lab.C.
PolicyNo o
• m an �0 LOCALI /
P y SIZE OF LOTI NO.OF BLD S.NOW ON LOT
❑ Certified copy is hereby furni hed. N ST CR S ST
Certified copy is filed with the county building inspection TRACT j BLOCK LOT NO. d
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USE Z NE IJAP NO.
department.
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Date •¢QQApplicant ( 6 Q 7 4"6 SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' o E //�L' TEL.NO,
COMPENSATION INSURANCE /" �®
ADD ITHIN 1000 Fr OF SCHOOL? ves No
ESS
(This section need not be completed if the permit is for one hundredL _ DISTRICT ���G111ROUP TYPE CONST.' FIRE ZONE OCESSE Y
dollars($hat or less.) CITY� y-^ �! ZIP 5 h //
I certify that in the performance of the work for which this permit ;��� lJ` (��� / �
is issued, I shall not employ any person in any manner so as to ARCHITECT Off ENGINEER TEL.NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
CONTRACTOR TEL.NO.
Exemption, you should become Subject to the Workers' / 7 , fir f��] ,/ „ `��1s7 SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith C� / V� fJ ffiJJJ FRONT
comply with such provisions or this permit shall be deemed revoked. A t)R S-5 q� LIC.NO. PL
K �J!/ /�/0 �• '`—�� 77 SIDE o-
LICENSED CONTRACTORS DECLARATION cl LIC.Cgs Pt a
0
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP v
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE N .OF STORES NO.OF FAMILIES O
Professions Code,and my license is in full force and epct. NEW ❑ BK PG U
DESCRIPTION OF WORK
License Number Lic.Class ADD U 64 re No TIO ` ti
Contractor Date — ALTER ❑ Z
REPAIR ❑ $
El am exempt under Sec. 4
BARC.for this reason DEMOL ❑ LDMA P/C#
Date: USE OF EXISTI BLDG. _ URM ❑
M/L o
Signature APP ANT(PRINT) TEL.NO. LDMA Perm#
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❑ I, as owner of the property, or my employees with wages as ,. O AC r a
their sole compensation, will do the work and the structure is D E f. -1l 1.I •a
not intended or )ered for sale (Section 7044, Business and + r �� Te^.�-q-0 PfOfeSS10nS Code. WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE AHAZARDOUS MAT IAL � -
J
❑ I, as owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q
P P Y Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project.(Section 7044, �.
Business and Professions Code.) ves❑ No❑ (jl�,oe—I e.o1 6% 4 j 913
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING �t^ All'
� •CSI
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH i li� _ All'
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST T
FOR GUIDELINES. /��
I hereby affirm that there is a construction lending agency for YES El NO 1:1SZR/ v�
the performance Of the Work for which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD
3097,Civ.Ci.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES JJ
is Lenders Name COUNTYCODE,TITLE CHAPTER 2.2 2.20.100 THROUGH 2. CONCERNING
HAZARDOUS
MATERIALS
REPRT NG AND FOR OBTAINING PERMIT FROM THE SCAQMD. 0-V 5/O4��
a Lender's Address
ER OR AG�
o 1 certify that I have read this application and state that the above P.C.FEE PERMIT FEE
information is correct. I agree to comply with all county 3�/ / T
ordinances and State laws relating to building construction,and F�i
hereb authorize representatives of this County to enter upon ISSUANCE FEE
th ve-m tioned pr pe f inspection pur oses.
i INVESTIGATION FEE TOTAL FEE ' 44C
m or Ap•nt Dab
SEE REVERSE FOR EXPLANATORY LANGUAGE p