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Home My Public Portal About5043ALESSANDRO AVE_Building (7) •' APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY .� WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS E hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRt7R O -, or a certificate of Workers'Compensation Insurance,or a certified Z - copy thereof(Sec.3800,Lab.C.) CITY TE f�)& Cf r fr T ZIP 6117 O LOCALITY--r ] Policy No. Company SIZE OF Y L f NO.OF BLDGS.NOW ON LOOT j/✓ ElCertified copy is hereby furnished. X� ( NEAREST CROSS ST. ❑ Certified copy is filed with the county building Inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. Date—Applicant ASSESSOR MAP BOOK PAGE PARCEL O L SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER� ILL/,�j � .( TEL.NO YES No COMPENSATION INSURANCE ' `� 2C�7 6 WITHIN 1000 FT OF SCHOOL? ADDRESS (This section need not be completed if the permit is for one hundred Q L�3 DISTRICT R TYPE C NST.' FIRE ZONE P O SS BY dollars($100)or less.) CITY ZIP R I certify that in the performance of the work for which this permit e19� G!T / 76 0 Is Issued, I shall not employ any person In any manner so as to ARCHITECT OR ENGINEER TEL.NO. become subject t0 the Workers'Compensation Laws. ST TIsTICA S FICATION PT CONDO Date Applicant ADDRESS (J _/—` CLASS NO. DWELL UNITS :L2 NOTICE TO APPLICANT. If, after making this Certificate OfCONTRACTOR �V(. TEL.NO. REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' SETBACK YARD HW<J PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L SIDE LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS P L 0 U 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 SQ; 'N(Y.OF STORES NO.OF FAMILIES C Professions Code,and my license is in full force and effect. NEW % BK PG I- DESCRIPTION OF WORK ADD ❑ VALUA 10 Poo, w License Number Lic.Class $ N PATIDate ALTER ❑ z ❑ � T�O o �,.� �c i am exempt under Sec. REPAIR El 1 h� BARC.for this reason DEMOL ❑ LOMA P/C# Date: USE OF tXISTING BLDG. 176-4 T-6 URM. ❑ Signature APPLICANT(PRIN (�i�/�/� TEL.N LDMA Perm# Z ❑ 1, as owner of the property, or my employees with wages as ""r'�N Z �a p their sole compensation,will do the work and the structure is ADDRESS D FINAL DATE Q _ not intended or offered for sale (Section 7044, Business and ur/�� Tl'�1 �d _.c Professions Code.) /�� =`,i I! lel-I a WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDO MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN (y/�y_J .... 1, as owner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY1 /:I�//% —!/ > licensed contractors to construct the project.(Section 7044, YES❑ Q Business and Professions Code.) NO TOTAL 105 . 25 WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPAIIR QUALITY MANAGEMENT DISTRICT M RICT(SCAQDOSEET REQUIRE A PERMIT FOR CONSTRUCTION OR MC COAST AATION PERMITTING CHECKLIST I.J7-I.ZD FROMITHESOUTH CONSTRUCTION LENDING AGENCY FOR GUIDELINES. � Zi� I hereby affirm that there is a construction lending agency for YES ElNO CHANGE 1E a1 t 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 . COUNTYCODE,TI TLE RAFTER 2.20 SECTIONS 2.20.100THROUGH 2.20.140 CONCERNING .B Lender's Name H RDO M I EP RTING FOR BT INGAPERMITFROMTHESCAQMD. 10111311-0001it 4I'YI 3. 1 CL Lender's Address ER OR AG 4 Il 't o' I certify that I have read this application and state that the above - �y, ,tri information is' correct. I agree to comply with all county P.C.FEE PERMIT FEE ordinances and State laws relating to building construction,and a- hereb authorize representatives of this County to enter upon ISSUANCE FEE e• v ned rope y for inspection purpsysesi _. �// INVESTIGATION FEE TOTAL FEE n 5 • .+un a glcem m ppm ome SEE REVERSE FOR EXPLANATORY LANGUAGE,