HomeMy Public PortalAbout5042ALESSANDRO AVE_Building (3) APPLICATION FOR BUILDING PERMIT
-COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING BUILDING ISD UY,
v
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Workers' Compensation Insurance,or a certified
copy there f,(Sec. 800,Lab.C.) CITY / ZIP
}' V C./ * T LOCALITY
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. I NEAREST CROSS ST.
- Certified copy is filed with the county'building i spection TRACT BLOCK LOT NO.
USE ZONE MAP NO.
de t ent. •1 i
Date Applicant� i ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNS (/,�TEL NO. m ,0_�/
COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDRESS
S � DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.)
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 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 REQUIRED' TOTAL SETBACK FROM EXIST
Exemption, you Should become Subject t0 the Workers' T"R TEL N �t SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith `J G -O Q
comply with such provisions or this permit shall be deemed revoked. FRONT
P ADDRESS LIC.NO P L
LICENSED CONTRACTORS DECLARATION �, 3J 2 8Z SIDE
CITY 41C L PL
I hereby affirm that I am licensed underprovisions of Chapter 9 ` SEWER MAP r
(commencing with Section 7000)Of Division 3 Of the Business and SO.FT.SIZE NO.OF STORIES NO.OF FAMILIES CL
Professions Code,and my license is in full force and effect. NEW ❑ BK PG ® �
Z p C_ nl DESCRIPTION OF WORK ADD ❑ VALUATION O:
License Numbar _ Lia Class f�
Contractor Date ALTER $ 200
❑ I am exempt under Sec. REPAIR N
$ z_
BAP.C. for this reason DEMOL ❑ LDMA P/C#
Date: USE OF EXISTI G BLDG. URM ❑
Signature 7 P tNylL � /O LDMA Perm#
❑ I.,as owner of the property, or my employees with wages as L � [� Z
their sole compensation, will do the work and the structure is ADDRE D� 4 t - -
not intended or offered for sale (Section 7044, Business and 'e, FINAL DAT �1j( Q' "
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL V l •� '
OR A MIXTURE CONTAINING AZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J }I=•)'"'
El I, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED O HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY ... _�••^'
licensed contractors to construct the project (Section 7044, vEs❑ No = €-�
Business and Professions Code.) -
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING _'••ri ;i
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _i:L`✓3':
CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES. ( ; j•? z_
hereby affirm that there is a construction lending agency for ves❑ No
a the performance of the work for which this permit is issued(Sec.
� I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING _
3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. ++'
TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS '"=i"`-LE—j14! i +=' -• ,�'
Lender's Name MATERIALPS �G�.GND FOWBBTTA1NINNGG A-,PERMIT FROM THE SCAQMD,
o Lender's Address U Y 1 I --
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 to comply P.C.FEE - PERMIT FEE
with all county ordinances and State laws relating to building
CO construction, and hereby authorize representatives of this unty I1 SUANCE FEE
ato en on a above ntioned property for insp��ti n�u pgse ,
�(3> `/� INVESTIGATION FEE TOTAL FEE
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SEE REVERSE FOR EXPLANATORY LANGUAGE