HomeMy Public PortalAbout5623ALESSANDRO AVE_Building (4) • • APPLICATION- FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILD,ING AD RESS
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I hereby affirm that I have a certificate of consent to self insure, 5-4d--5 P�-j
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.W,Lab.C.)) f c ITr ZIP LOCALITY
Policy No. 6 6 6 7,q 7.6 Company A--u4 4 SIZE OF LOT NO.OF BLDGS.NOW ON LOT -
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I❑7-Cert)f•led copy is hereby furnished. NEAREST CROSS ST
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1� Certified Copy is filed With the CO ty bUlldl In paCtiOn TRACT BLOCK LOT NO.
USE ZONE MAP NO.
department.
Date 0` • ' ice Applicant ASSESSOMAP BOOK PAGE FARCe96,1 1E SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER iCly TEL.NO. YES NO
COMPENSATION INSURANCE ADDRESS WITHIN 1000 FT OF SCHOOL?
��(This section need not be completed if the permit is for one hundred L//I DISTRICT GROUP TYPE CONST: FIRE ZONE PROCESSED BY
dollars($100)or less.)
CITY �J I ZIP J X
I certify that in the performance of the work for which this permit /Hi i Q Q � '3
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 to the Workers C6sON�•TRACT R TEL.NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith 1AJ�s FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESSLIC.NO. P L
6 SIDE }
LICENSED CONTRACTORS DECLARATION CITY LIC.C PL a
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I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP v
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE O.OF STORES NO.OF FAMILIES
Professions Code,and my license js in full force and effect. 0 NEW ❑ BK PG
dY - DESCRIPTION OF WORK �^ ADD ❑ VALUATION ► W
License Number Lic.Class - 0O a
I-E-iroc r' e kSIPtA
Contra 7r' Date �` ! L i I ALTER ❑ � /070 z
El am exempt under Sec.
' REPAIR X
B.BP.C.for this reason (Q-% I P S n DEMOL ❑ LDMA P/C#
Date: USE OF EXISTIT BLDG kJ
URM ❑
Signature A�P pLCA TIP INTI TEL.NO.
9 f•l ( I S � �S �� LDMA Perm# Z
❑ I, as owner of the property, or my employees with wages as 1' p
III their sole compensation, will do the work and the structure is ADDRESS /
not intended or offered for sale (Section 7044, Business and Air, S ACI 1'^I n G S FINAL DATE Q
Professions Code.)
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL111sh7- J
❑ I, as owner of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q
Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BIV
,
licensed contractors to construct the project (Section 7044, YES El NO
Business and Professions Code.)
i WILL THE INTENDED USE OF THE BUILDING 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(SCAQMD)SEE PERMITTING CHECKLIST
FOR GUIDELINE$.
I hereby affirm that there is a construction lending agency for YES ElNO ZJ
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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 � EOUIREMENTS UNDER THE LOS ANGELES
COUNTY CODE,TIT 2 APTER SEC NS220.100 THROUGH 2.20.140 CONCERNING _
o Lender's Name HAZA♦�pQUS MATEPOR AN OR OBTAINING A PERMIT FROM THE SCAQMD.
aLenders Address OWNER OR AGENT— 4
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0 1 certifythat I have read this application and state that the above
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information is correct. I agree to comply with all county P.C.FEE PERMIT FEE
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ordinances and State laws relating to building construction,and
a hereby authorize representat'ves of this County to enter upon ISSUANCE FEE 7
the abo �51—
ve-menti ed pr pe for inspection purposes. /
-; INVESTIGATION FEE TOTAL FEE / / '
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Sign m M Appli—w AqM Date cy
SEE REVERSE FOR EXPLANATORY LANGUAGE