HomeMy Public PortalAbout5816ALESSANDRO AVE_Building APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES + BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDIN �Df2ESS
I hereby affirm that I have a certificate of consent to self insure, BUILDING DDRESS
or a certificate of Workers' Compensation Insurance, or a certified 11, e ;q ApAve—
copy
vecopy thereof(Sec.3800,Lab.C.) CIJr `,
C \ ZIP
9/7?-(/ LOCALIT)017
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. O
1 NEAREST CROS ST
❑ Certified copy is filed with the County buil-ding inspection TRACT BLOCK LOT NO.
USE ZONE MAP NO.
department.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' ow TEL NO.
COMPENSATION INSURANCE IZ U �CC � Z WITHIN 1000 FT OF SCHOOL? Yes No
(This section need not be completed if the permit is for one hundred ADDRESS / g , n
�e b /v 6 0-90,__. 1 e DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100) or less.) !�'�CCCiii���
I certify that in the performance of the work for which this permit CIT.YJ C t Z 7 0 - () D f/
is issued, I shall not emAll
ploy any erson in any mann" as to ARCHITECT OR ENGINEER TEL NO. O
become s bject 0 the Workers' n Law STATISTICAL CLASSIFICATION APT CONDO
\Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE T AP LICANT.• If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you Should become Subject to the Workers' CON ACTOR TEL NO Q' f (/ SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith G �jv A, / �! fO 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 SO.FT.SIZE NO.OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. NEW BK PG ,
a
.License Number Lic.Class DESCpIPTION OF WORK ADD ❑ VALUATION �" O
Contractor Date ALTER ❑ �
El am exempt under Sec. REPAIR El
B.BP.C.for this reason DEMOL ❑ LDMA P/C#
Date: USE OF EXISTING BLDG. URM ❑ °"•:•`" a a
Signature App (PRIL ��� �yL i•f �� LDMA Perm# Z --- _ -••
❑ 1, as owner of the property, or my employees with wages as vim.o 7 q `•'S,_ -f 3 a .i F—
their sale compensation, will do the work and the structure is AElDRES0 1
not intended or offered for sale (Section 7044, Business and 1'r1,eS FINAL DATE Q
v' JL
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIALiy'?
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE s J
❑ 1, as owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINALBY
licensed contractors to construct the project (Section 7044, ves[I No El -_-r* i L i a
Business and Professions Code.) T i eft
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
CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR .s i_I( E- --F
GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ No❑ IC=HSL. 17.1 :
N the performance Of the work for Which this permit IS issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING
° 3097,Civ.
ao C.) CITLE 2 H UNDERSTAND MY
Q2U2IREMEN ONUGEHRT.2H0E.LOS ANGELES C
OUNTY CODE,
0TO140 CONCERNING HAZARDOUS
Lenders Name MIT FROM THE SCAQMD.
Lender's Address
O ,
_ L-•E--{{{r7''ft,d•i.
*�L - 4_'
o I certify that I have read this application and state under penalty _ r,; -
o P.C.FEE "�O PERMIT FEE Am
of perjury that the above information is correct.I agree to comply �Q j `j3,'i} j 'Y-
6 °1_f
with all county ordinances and State laws relating to building
construction and hereby authorize representatives of this County ISSUANCE FEEoo
to ebove;,prned property for inspeo urp es. l/p
INVESTIGATION FEE TOTAL FEE
au,of Applicant a,Agent Da
SEE REVERSE FOR EXPLANATORY LANGUAGE