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APPLIGATIOt+ -OR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS a
I hereby affirm that I have a certificate of consent to self insure, BUJIy�%D ESS`iy'_ (�/j_,� L
or a certificate of Workers' Compensation Insurance,or a certified �cJ ✓S /� SSr`n"" -0
copy there�l/o�f(Sec.3800,Lab.C.) fr,�� Q ZIP f J( ,1'^1
Policy No('�°J�'�CU�� Company rl ( / UCS/ LO ALITv
i SIZE OF T I NO.OF LDC .NOW ON LOT -�
Certified copy is hereby furnished. // NEAREST CROS ST
❑ Certified copy is;filed with the c unty Wildin 'nspection TRACT BLOCK LOT NO..
department •//1�1� USE ZONE MAP NO.
Date/D-1(43 Applicant • / J ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' o R ^ ^,� C F j TEL NO. YES NO
COMPENSATION INSURANCE �gA-AJ If /�/� a/J -F��. WITHIN 1000 FT.of SCHOOL?
(This section need not be completed if the permit is for one hundredA D `.CSI DISTRICT GROUP T ONST. FIRE ZONE PROCESSED BY
dollars($100)or less.) J
I certify that in the performance of the work for which this permit C ZIP ^ �� _
is issued, I shall not employ any person in any manner so as to /
become subject to the Workers'Compensation Laws. ARCHITECT/OR ENGINEER TEL NO.
P STATISTICAL CLASSIFICATION APT CONDO
Date :rApplicant ADDRESS CLASS NO, 4 DWELL UNITS _
NOTICE TO APPLICANT.', If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should. become subject to the Workers' CONTRACTOR C , L..NQ. 055-3
�� SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith CS:1tC
FRONT
comply with such provisions or this permit shall be deemed revoked. All S � LSC.NO� P L
LICENSED CONTRACTORS DECLARATION ll ' SIDE
CIT LI�IC�LAS P L
I hereby affirm that'I am licensed underprovisions of Chapter 9 ' _A'6 `�, P SEWER MAP }
(commencing with Section 7000)of Division 3 of the Business and SQ ET SIZE NO.OF STORIES NO.OF FAMILIES d
Professions Code,and my license is in full force.an effect. / NEW ❑ BK PG , 10
License Number L-7 3&_ q'7 Li0. ClaSS _ �C, D RIPTION OF W . ADD ❑ VALUATION V
Contractor 01 /'I V��i4i pate ��'t — 1 em ��p� SY( ALTER ❑ � ��eQ' ~�
❑ I am exempt under Sec. OJ "� f " 2- e� REPAIR ❑
V
BAP.C. for this reasone-0/1� DEMOL El LDMA P/C# W
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t USE OF EXIS / URM ❑
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Signature\ /�, — � A_p�I/CAN .T(PRINT) / L OLDMA Perm
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I, as owner of the property, or my employees with wages as 0/r/C S (� OSS3 Z -s e;t-'
their sole compensation, will do the work and the structure is ADDRES" V n ''� O i 1 1 .::s
not intended or offered for sale (Section 7044, Business and 6C
(�V f tV 14 FINAL DATE a TOTAL 134 .25
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 2
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 1'I ~� J
❑ 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY •E��K
licensed contractors to construct the project (Section 7044, _�
aE1
Business and Professions Code.) ves CJ No El ;,y4�i!'�f�L .I
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 COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES.
I hereby affirm that there is a construction lending agency for YES El NO❑ 0 II�}'_t—_i;_I0141 s 3?'
N performance
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nf1Ce Of the work for which this permit IS issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING - •_L(L,+� Ari -35
3a.'5
3097
) - 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
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
o Lender's Address
OWNER OR AGENT
o I certify that I have read this application and state under penalty
0 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE /:op
o with all county ordinances and State laws relating to building d
c .5 ruction, and reby authorize representatives of this County ISSUANCE FEE j O
t er upon the b e�tio prope"rt for inspection purposCe�s T
a �0—!
INVESTIGATION FEE TOTAL FEE
awry o1 Appi-nt or Again oa�o
SEE REVERSE FOR EXPLANATORY LANGUAGE