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HomeMy Public PortalAbout5761ALESSANDRO 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 RESS I hereby affirm that I have a certificate of consent to self insure, LA ALF— R-0 FCITYZIP UILDING A DRESS or a certificate of Workers' Compensation Insurance,or a certified SS A�� copy thereof(Sec.3800,Lab.C.) �r t'1�� LOCALITY Policy No. ���--9 .s �T/�Tl✓ �l�I � Company T CSIZE OF LOT NO,OF BLDGS.NOW ON LOT Q ❑ Certified copy is hereby furnished. NEAREST CROSS CF. Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. Z-13-�iS Date Applicant .53 AQc"K-0il"1 BCOF: ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS ��© �/ OWNER TEL NO. YES NO ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' b19-"���- Z3• COMPENSATION INSURANCE ADDREtAUSS S WITHIN 1000 FT.OF SCHOOL? (This section need not be completed if the permit is for one hundred S' A� SCC DISTRICT GROUP TYP CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) �"`-'�.��J CITY 1ZIP� `� y I certify that h the performance of the work for which this permit •'t�`Gcrl_rl `�� �/N ' is issued, I shall not employ any person in any manner so as to �' /� be ome subject to the Worker 'COm enSatiOn Laws. 6val ARCHITECT OR ENGINEER TEL NO. ` P STATISTICAL C g($SIFICATION APT CONDO to Appli ADDRESS CLASS NO. V' DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of REQUIRED' TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' �pNTRACTOR TEL NO. L C� SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith Lei\ Z FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION lot3-2- i3 i Rte 3833 SIDE , j�Y,^rn LIC. ASS � PL I hereby affirm that I am licensed underprovisions of Chapter 9 ��T ` SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORIES NO.OF FAMILIES a Professions Code,and my license is in full force and effect�j NEW El BK PG Ov License Number ``l3 83 38 Lic.Class L— ` JX�SCRIPTION OF WORK ADD ❑ VALUATION z A-?-9s o�F � $ 2—t S 85 s00 Contractor �I1�rA �� Date ALTER ElL') SUJ Aei )�JG �' REPAIR ❑ a ❑ I am exempt under Sec. $ Z B.&P.C.for this reason `TIS I 1 L- '9�? -,1)CL�-J oft V-Qj- DEMOL ❑ =P/C, Date: Ls�©S� S CS 111 7L URM ❑ Signature APPLICANT(PR/NT) EL NO. LD-MA Perm ❑ I,as owner of the property, or my employees with wages as VA- %LcZ S_CIO, Z a their sole compensation, will do the work and the structure is ADDRESS Op not intended or offered for sale (Section 7044, Business and �L C'�T l 1 g d FINAL DATE Q _ y 'F Y Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE I, as owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL Y licensed contractors to construct the project (Section 7044, Business and Professions Code.) YES 1:1 No❑ ;i_`:; ,{, •� -g ..-_ WILL THE INTENDED USE.OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING i'- OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH {'_i_i•� _.L_x ... CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES I hereby affirm that there is a construction lending agency for ;'31,3 E R l.: YES❑ NO❑ a the performance of the work for which this permit is issued(Sec. 3097,Civ.C. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING N ) CHECKLIST,I UNDERSTAND MV REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS Slf,ij 2..^j Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. - - ^• "' 0 Lender's Address 0 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 N with all counLYJOLdL ances and State laws relating to building mconst eti n, and here authorize representatives of this County hSSUANCE FEE ` D nter up the ab -ment' ed property for inspection purposes. a Z-/.ms INVESTIGATION FEE TOTAL FEE ? sgn,c„re.ol Applicant or Agent 0e1e /d/;" �/ SEE REVERSE FOR EXPLANATORY LANGUAGE