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HomeMy Public PortalAbout5750ALESSANDRO AVE_Building (2) APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS G or a certificate of Workers' Compensation Insurance,or a certified 6a e 5scfi I,O copy thereof(Sec.3800,Lab.C.) CIT7r M ilI' ZIP r•��� / LOCALITY Policy No. Company SIZE OF LOT I NO.OF BLDGS.NOW ON LOT ❑ Certified Copy is hereby furnished. NEAREST CROSS ST. JJ{ ❑ Certified Copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO Date Applicant ASSESSOR MAP B OK PAGE PARCEL © ,J ., � SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' W R /VI TEL NO. ` G' COMPENSATION INSURANCE �n / "► l 22� -7-1931WITHIN 1000 FT.OF SCHOOL? ves No This section need not be completed if the permit is for one hundred AD KESS f G ( P P o 6 S✓�%1,�1��� DISTRICT GROUP TYPE CONST. FIRE ZONE - PROCESSED BY dollars($100)or less.) U VV„�6 n n ` zIP . U 1 Z, I certify that in the performance of the work for which this permit r Clay- (.�h ( �! is issued, I shall not employ any person in any manner so as to ARCHITECT IbR ENGI R TEL NO. become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO - '” Date -q� Applicant(/w4• 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' CONTRACTOR /J/ TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith !/Y7/ FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION SIDE CITY LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP >- (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW ❑ BK PG ® O License Number Lic.Class DESCF/J I OF WO ADD ❑ VALUATION ce Contractor Date �� � ca VrY(>n ALTER 1:1 $ 3 ���� O ` U I^C. .4 r/l •'ems/ REPAIR ❑ w ❑ I am exempt under Sec. $ a C/) Z B.&P.C. for this reason DEMOL ❑ LDMA P/C# Date: USEEXIS I G BL URM ❑ I� I� v Signature - APPLICAN_ PRINT) TEL W. N LOMA Perm# �• y� 1„as owner of the property, or my employees with wages as O/tA ' � 3 0 Z q; , 1�. their sole compensation, will do the work and the structure Is ADDRESS Or not intended or offered for sale (Section 7044, Business and J 7 91D 'f 55CI A 4,110 FINAL DATE " ' Q _ ;_s;�+ ]`�,­J Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 5 OR A MIXTURE CO 7AINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE V" J i 1T I, as Owner of the property, am exclusively contracting with AMOUNTS SPECIFI ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY _ licensed contractors to construct the project (Section 7044, - P VES❑ NO ~Z ATAI �� � o �=d Business and Professions Code.) 1 `•�` _ WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING •� k'' —`'•' OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH DD '�_![L't.•!'. '�"" CONSTRUCTION LENDING AGENCY COAST AIR QUALMANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR y, GUIDELINES. !!G//� ((// - ice':..(:' 'L z%�E•` I hereby affirm that there is a construction lending agency for YES❑ No ! r� N the performance Of the Work for which this permit IS Issued(Sec. [HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ✓� - 3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,CM f•.__ter. ! :r'u TITLE 2.CHAPTER 2.20 SECTIONS 2 20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS ) ,1�I1�j 1„?C,.)a i i i 3.7 Lender's Name M E LS REPORTING AND FO O AININ A PERMIT FROM THE SCAQMD. EL Lender's Address s•!1 " OWNER OR AGENT O o I certify that I have read this application and state under penalty O P.C.FEE PERMIT FEE of perjury that the above information is correct.I agree to comply N with all county ordinances and State laws relating to building d construction, and hereby authorize representatives of this County ISSUANCE FEECO toe r upon the above-mentio ed grope ty for inspectio purposes. (C3 y - -7"} 7-1[� INVESTIGATION FEE TOTAL FEE ^`xsgnam .1 Andy m m i df SEE REVERSE FOR EXPLANATORY LANGUAGE