HomeMy Public PortalAbout5031ALESSANDRO 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, BUILDIN AQDRE� 7
or a certificate of Workers' Compensation Insurance, or a certified OQ4�Y'
copy thereof (Sec.3800,Lab.C.) CITY N ZIP
LOCALITY
Policy No. Company SIZE OF LCT F BLDGS.NOW ON LOT
E3Certified copy is hereby furnished.
NEAREST CROSS
El Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department.
USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' ER TEL NO.
COMPENSATION INSURANCE - tom 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.) DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
CITY ZIP
I certify that h the performance of the work for which this permit ��� 3
bissued, I shall not employ any person i any manner so as to
become subject to the Workers Com en tion La ARCHITECT O ENGINEER TEL NO.
STATISTICAL CLASSIFICATION APT CONDO
Date �pplic:", 1 � ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT.' vlome
er making this ' ertificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should Subject to the Workers' GONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith L P C 92 D FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L
LICENSED CONTRACTORS DECLARATION ! l GS SIDE
CIT LIC.CLASS P L
I hereby affirm that I am licensedep
underprovisions of Chapter 9 1 f GG r /v SEWER MAP }
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES d
Professions Code,and my license is in full force and effect. NEW BK PG , V
,.�ticense Number v 7 Lic. Class DESCRIPTI 9F WORK ADD ❑ VALUATION
Contractor Date 10 -2/ —9 Zl ALTER ❑ O�
O
❑ 1 am exempt under Sec. REPAIR ❑ ':t.t os U
B.&P.C.for this reason ( 3� DEMOL ❑ a
LDMA P/C#
Date: USE OF EXISTING BLDG. URM ❑ .� N
Z
Signature APPLICANT(PRINT) TEL NO. LDMA Perm# {'-
❑ I, as owner of the property, or my employees with wages as Z i0i 'Ii
their sole compensation, will do the work and the structure is ADDRESS O 'LI •'• -
,
not intended or offered for sale (Section 7044, Business and FINAL DATE
Professions Code.) G 1 iPIS
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL fZ- Z I��3
El 1, as owner of the property, am exclusively contracting With ORA MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q 60 30
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY � ! L �. m
licensed contractors to construct the project (Section 7044,
Business and Professions Code. ves 1:1 No❑ r•Ati-�
_
1=�=.ji 9
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION.FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COHAN
AST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKUST FOR 13C 4`
GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ No❑
N the performance of the work for Which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, I��IL!i�`.'.3=1 L !'•Sr a:..rJ f-
TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS _
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. �f
o Lender's Address
O OWNER OR AGENT
I certify that I have read this application and state under penalty
of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
N with all county ordinances and State laws relating to building L�
m construction, and hereby authorize representatives of this County ISSUANCE FEE lo,
ID to en pon th bove-m ed pro erty for inspection purposes. f�
L,. ���' INVESTIGATION FEE TOTAL FEE /7
D /� L/
t ApPI, n t w Aye„ Dale (/
( 1 SEE REVERSE FOR EXPLANATORY LANGUAGE