HomeMy Public PortalAbout5721ALESSANDRO AVE_Building APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN I BBUILUINGADDRESS_� .Silzg .S
I hereby affirm that I have a certificate of consent to self insure, Bul RES :�
or,a certificate of Workers' Compensation Insurance,or a certified
copy thereof(S .J 800,Lab.'C.) •��� CITY .� �,. ZIP - / ' LOCALIT
Polic o. Compan;A��/� ' V f
SIZE OF LOT. N .OF BLDGS.NOW ON LOT
Certified copy is hereby furnished. NEAREST CROS ST.
❑ Certified Copy is filed with the my building S ction TRACT BLOCK LOT NO.
de tment. USE ZONE MAP NO. ,
Date baa Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTI ROM WORKERS' ow / r�� `EL NO. YES NO
COMPENSATION I SURANCE (, t r WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred ADDRESS
DISTRICT GROUP CONST. FIRE ZONE PROCESSED BY
dollars($100) or less.)
CITY ZIP
ZIP �Q�
I certifythat in the performance of the work for which this permit
is issued, I shall not employ any person in any manner So as t0 ARC ITECT OR ENGINEER TEL NO.
become Subject to the Workers'Compensation Laws. STATISTICAL CL SIFICATION 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' CONTRACTOR s� TEL �7 SET BACK YARD HWY 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, / LI .N P L
LICENSED CONTRACTORS DECLARATION ` � SIDE
�. _ LI .CLASS � P L
I hereby affirm that I am licensed underprovisions of Chapter 9 C� SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SQ.FT IZk2 NO.OF STO S NO.OF FAMILIES
Professions Code, nd licens Is in full force and eff t. /�� NEW ❑ BK PG �
License Number - _ �� Lia Class PIPTION OF WORK ADD ❑ VA ON , Q
�f/F ®VS' l-�f�R /i l e/ U
Contractor��J�.��/7f/� rI%oate ALTER ❑ ��
df/ REPAIR $
❑ 1 am exempt under Sec. y
MOF
�5l7y')r117ill- Ppr/i DEMOL ❑ U
B.&P.C.for this reason
LDMA P/C# �J,J
3 Dat BLDG. URM ❑ U)
Signature �1 APPLICANT(PRINT) TEL NO. LDMA Perm# z
❑ I, as owner of the r er y, or my employees with wages as ZO Ai. "f' s
their sole compens�§fOn, will do the work and the structure is ADDRESS i ° .
not intended or offered for sale (Section 7044, Business and FINAL DATE Q .�,t
Professions Code.) J = I:� °
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
❑ 1, as Owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE FINAL B i ''I TTIENS
P P Y. Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE?
licensed contractors to construct the project (Section 7044,
Business and Professions Code.) VES❑ No 1:1 �( 1�-°
,.#gian .dam•..^g''�',
WILL.THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
O �ir`$'e i•a'
CONSTRUCTION LENDING AGENCY CAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR "'HECK
GUIDELINES. _ -CH
�r-h[ S'
1 hereby affirm that there is a construction lending agency for GUI ❑ No❑ {�HHA NGE °s jj's•
a the performance Of the work for which this permit Is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTNG
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 f'i�.1-i
I(� i i Qf'f y}--973
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. !� '= ^
o !Lender's Address OWNER OR AGENT ' Av°14
0
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 n
with alunty ordinances d State laws relating to building IleOY
constr ctio , and hereby a rize representatives Of this County ISSUANCE FEEco '
" ent the aoov -m n d property f Inspection purposes.
IL INVESTIGATION FEE TOTAL FEE
s�aawre or APorca�t�Al Dara
SEE REVERSE FOR EXPLANATORY LANGUAGE