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HomeMy Public PortalAbout5031ALESSANDRO AVE_Building (3) APPLICATION FORBUILDING PERMIT COUNTY OF LOS ANGEL'S 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 or a certificate of Workers' Compensation Insurance,or a certified Sc;;,15 A VC copy thereof (Sec.3800,Lab.C.) CI �M ��. �� r ZIP LOCALITY Policy N0. Company Or IZE OF LOT NO.OF BLDGS.NOW ON LOT '�Z •�' ❑ Certified copy is hereby furnished. NEAREST CROSS /j�T_. Gait ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. / ASSESSOR MAP BOOK PAGE PARCEL Date Applicant D � / P i (p SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNE TEL NO. COMPENSATION INSURANCE [ WITHIN 1000 FT.OF SCHOOL? Yes No (This section need not be completed if the permit is for one hundred ADDRESS dollars($100) or'less.) ww�� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY sem_ � S-i7N0 G` 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 t0 gRCHITEC OR ENGINEER TEL NO. le- become subject to the Work/fter ' ns tion Laws. STATISTICAL CLASSIFICATION APT CONDO Date�D--/-93 ApplicanADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT: aking t Certificateof REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should ubject to the Workers' C TR T TEL NO. Q/p SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith ,y FRONT _ Comply with SUCK provisions Or this permit Shall be deemed revoked. ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION 37 e�>e D Lv� j PILE ILIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 11111LIt a (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES SEWER MAP Professions Code,and my license is in full force and effect. H 19 � NEW BK PG , V LicenseNumb r 70 Lic.CIaSS DESCRIPTION OF WORK ADD ❑ VALUATION Contractor Date !�` ^ Q� ( ALTER El 1:3 C9 $ . - ©d,P� ❑ lam ' empt under Sec. REPAIR El ~ U BAP.C.for this reason DEMOL ❑ LU LDMA P/C# G. Date: USE OF EXISTING BLDG. URM 11 Z Z Signature APPLICANT(PRINT) TEL NO. LDMA Perm# Al j a g E] 1, as owner of the property, or my employees with wages as Z - � 50 YD their sole compensation, will do the work and the structure is ADDRESS O I°_':St- not intended or offered for sale (Section 7044, Business and FINAL DATE Q a Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL s El ,' / z Z. �/ ,3 � 1, as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE i f AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project (Section 7044, ❑ I //� � ?!-� [t 1 m Q f Business and Professions Code.) VES 1:1 NO `.[� L••_3.=° WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING � _. OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ;.1 i I I EE S CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR n GUIDELINES. /h/U/GL`-��� �• 727 - 11 I hereby affirm that there is a construction lending agency for YES❑ No❑ �_ !!-I i'A` C4 the performance of the work for which this permit is issued(Sec. { ` 7_;-? p> I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING CHECK •�- m�L 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 CHANGE �..(•'` � •bV3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. S_ i!'�'.� ° 'I'` o Lender's Address O OWNER OR AGENT oiI certify that I have read this application and state under penalty 1,f s;—!! i O of perjury that the above information is correct.I agree to comply P.C.FEE ,) PERMIT FEE I-k-•-�- . Ili -�/ •�'• with all county ordinances and State laws relating to building v `� CO �� � 1 Alm! 9 m construction, and hereby authorize representatives of this County ISSUANCE FEE ato enter upo�theabo e- ientione�roperty for inspection purposes.ID Y INVESTIGATION FEE TOTAL FEE• ofAppyDofo SEE REVERSE FOR EXPLANATORY LANGUAGE