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Home My Public Portal About5025ALESSANDRO AVE_Building (2) APPLICATION FOR: BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS .-Raas or a certificate of Workers'Compensation Insurance,or a certified ?9'Z--5 ` e-- A >wo copy thereof(Sec.3800,Lab.C.) cIT�7+�1 1 U1 1-r ZIP LOCALITY Policy No. 2� /7¢�Compan �'�� SIZE OF LOT L l NO.OF BLDGS.NOW ON LOT ❑ Certified Copy IS hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. DateZApplicant �� e ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER / TEL NO. COMPENSATION INSURANCE �C G Or7-� WITHIN 1000 FT.OF SCHOOL? YES NO ADDRESS (This section need not be completed if the permit is for one hundred 6Z z5 LAS DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) CIT ZIP I certify that in the performance of the work for which this permit �vQ, l�a7 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. DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of -GAUJ.eAl-19—/ REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become Subject to the Workers' CONTRACTOR TEL.NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith 0 /S�9 L LIC.NO. FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS�S r /y PL (.°v�•dam' S SIDE LICENSED CONTRACTORS DECLARATION CITE' LIC.C sS PL o I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW ❑ BK PGPON-- 00 License Number Lic.Class 16 DESCRIPTION OF WORK ADD ❑ VALUATION d wo Contractor)�,, eek- 7-ZO 9 L ALTER ❑ $ Z 0 O O ' z E�o 0rREPAIR El $ El am exempt under Sec. B.&P.C.for this reason C 0 44 Po s DEMOL ❑ USE OF EXISTING BLDG. LDMA P/C# Date: [LIRM ❑ Signature APPLICANT(PRINT) TEL.NO. LDMA Perm# - ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is ADDRESS �,•._ :-:r••. not intended or offered for sale (Section 7044, Business and FINAL DjA'�7gj�- Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL �/ ;w '•° -M v ❑ 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, YES❑ NO❑ /�lY/ {Y Business and Professions Code.) - '''- _ - WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH `-••'-R-�^ CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. .e gr•FI�:a1I� _ _ 1 hereby affirm that there is a construction lending agency for YES❑ No❑ 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.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES m. COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 220.140 CONCERNING f-°3.:4•+'- :_` - 1J Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. . aLender's Address Q OWNER OR AGENT o I certify that I have read this application and state that the above FEE P.C. PERMIT FEE information is correct. I agree to comply with all county p ordinances and State laws relating to building construction,and I J Q ¢. hereby authorize representatives of this County to enter upon ISSUANCE FEE �f /�� tl g d perty for inspection purposes. oC�L/L ¢ (l 7 �� f Z INVESTIGATION FEE TOTAL FEE Slpnebn of ApplMsnl a A1pnl Deb SEE REVERSE FOR EXPLANATORY LANGUAGE