HomeMy Public PortalAbout5801ALESSANDRO 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 _ ✓�
or a certificate of Workers' Compensation Insurance,or a certified a-o At e`5S4A1P v �}
co thereof(Sec.3800,Lab.C.) CITY_ ZIP
PY IF N )( E- C.I T Y 9/7 R"D LOCALITY
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT i -G
❑ Certified copy is hereby furnished. X I U- 0 NEAREST CROSS ST.
❑ Certified copy is filed with the county building in TRACT BLOCK LOT NO.
department.
USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER / TEL NO.
OF SCHOOL?
1' owe C'�.Q� IP/00-�7_3 3 0 WITHIN 1000 F
V T. YES NO -
COMPENSATION INSURANCE M �
(This section need not be completed if the permit is for one hundred ADDRESS
a A LT-S5,4AI v,? e DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.)
7
I certify that in the performance of the work for which this permit CITY TF-H & C l T T ZIP / �O�
is issued, I shall not employ any person in any manner s0 as to ARCHITECT OR ENGINEER TEL NO. J �i
become subject to the Workers'Compensation Laws. Nei Ia Ir z G/V� STATISTICAL CLASSIFICATION APT CONDO
�+--�' —33��•
Date Applicant ADDRESS J
CLASS NO. --C'/ DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate Of Slxt 0 02+ f �"� 9/7a'4 REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you Should become subject t0 the Workers' CONTRACTOR EL NO. V SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith A//g • FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L
LICENSED CONTRACTORS DECLARATION SIDE
CITY LIC.CLASS PL
I hereby affirm that I am licensed underprovisions of Chapter 9SEWER MAP
ST
E----[with Section 7000)Of Division 3 Of the Business and SQ.FT.SE NO.OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. 57 I f
License Number Lic.Class ADD NEW 11 BK PG , >-
DESCRIPTION OF WORK VALUATION O
Contractor Date Pad 'e"m ALTER ❑ $
12
ElI am exempt under Sec. t I °"', REPAIR El $
B.&P.C.for this reason DEMOL ❑ U
LDMA P/C
Date: USE OF EXISTING BLDG. URM ❑ C-
��Signature APPLICANT(PRINT) TEL NO. LDMA Perm# - Z
UYI, as owner of the property, or my employees with wages as Z - 'u` -J,
-
their sole compensation, will do the work and the structure is ADDRESS O
not intended or offered for sale (Section 7044, Business and FINAL DATE /n�/1 Q '•
PfOfeSSIODS Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL .y j-7Sti.4.i „
ORA MIXTURE CONTAI NG A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
El 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project (Section 7044, YES❑ NO
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING _ -)CA yyp
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ,
CONSTRUCTION LENDING AGENCY GOO ST AIR
IESQUALIITTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR I "f 1-1'i fel 'k yw �
I hereby affirm that there is a construction lending agency for YES❑ No LW I '°°
a the performance of the work for which this permit is issued(Sec. )-HI1=c V
[HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING -r `
3097, Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, `10
" x
TITLE 2,CHAPTER 2.20 SECTIONS 2,20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS "`s=- �+ (`=
3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
oLender's Address
O 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.1 agree to comply P.C.FEE 1a��CJ PERMIT FEE _
o with all county ordinances and State laws relating to building
construction, and hereby authorize representatives of this County ISSUANCE FEE
to r upon the above-ment'nned property for inspection purposes.
l ��j,� .�/ •-p� INVESTIGATION FEE TOTAL FEE
r Sgn lur of ADDIi 1 or Agent D to
SEE REVERSE FOR EXPLANATORY LANGUAGE