HomeMy Public PortalAbout5937ALESSANDRO AVE_Building (4) APPLICA , ION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES '4`'' BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRES
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 f L -_sNmo A
copy thereof (Sec. 3800,Lab.C.) CITY ZIP
Tei L T q 118 0 LOCALITY of 0
Policy No. Company SIZE OF LOT NO,OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. X I �JC�. ' NEAREST CROSS
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. /
department.
tC/ USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PGE P.RCEL
00 d� SPECIAL CONDITIONS ��� /
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER 1 U TEL NO.
COMPENSATION INSURANCE x`11 "L. S WITHIN 1000 FT.OF SCHOOL? Yes No
(This section need not be completed if the permit is for one hundred ADDRESS
"I }' G,.S`'. � � DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100) or less.) J► '
CITY ZIP
I certify that in the performance of the work for which this permit 'Tv_�L& �T C/ �O� d3
is issued, I shall not employ any person in any manner s0 as t0 ARCH OR ENGINEER TEL NO.
become Subject to the Workers'Compensation Laws. - ,, STATISTICAL CLASSIFICATION APT CONDO
< a�v c' ' Cz43J 8df _L . _3 �
Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT. if, after making this Certificate of REQUIRED TOTAL SETBACK FR6M EXIST
Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. 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 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..SIZENO.OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. D, I NEW ❑ BK PG d
j License Number Lic.Class D SCRIPTION OF WORK ADD ^� VALUATIONloop. O
Contractor Date �-V Fd A-Criz DeOP-m1� [ /�
$
ALTER ❑ /r/
EJ I am exempt under Sec. cc
�T ®, iI t' R12&1;� REPAIR El $ 0
B.BP.C. for this reason R��00 i���� DEMOL ❑ LDMA P/C# W
Date: USE OF EXISTING BLDG. URM ❑ IL
(� Signature APPLICANT(PRINT) TEL NO. LDMA Perm# '•' _ Z
El 1, as owner of the property, or my employees with wages as'
their sole compensation, will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DAIE
0
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J
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 BY v F'�»'='• _
licensed contractors to construct the project (Section 7044,
Business and Professions Code.) WILL
11 No El �L ;'1_
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING � -• .
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH •-• -..---�-* '• �" -�' c a „'";" =•'i k"k:'_'
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKUST FOR 04 -
A k Ci fJ
GUIDELINES. V 4 - -j"' I 15-20-= 7 '
�.a cc— 3
I hereby affirm that there is a construction lending agency for YES❑ No❑ V Y� i- ' � .�' u�
N the performance Of the work for which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ""'i+ f•e
3097, CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
TITLE 2,CHAPTER 2.20 SECTIONS 2.20,100 THROUGH 2.20.140 CONCERNING HAZARDOUS
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. i -I+� iij
3 - :riN1,
o Lender's Address
OWNER OR AGENT
O
0 1 certify that I have read this application and state under penalty _ �•.. r�.:#—;:,�;-I
of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
o with all county ordinances and State laws relating to building r-r F -
M const/ ction, and hereby authorize representatives of this County SSUANCEFEE ��
to r on the above-mentioned property for inspection purposes-
¢ __J�� INVESTIGATION FEE TOTAL FEE
o -
SEE REVERSE FOR EXPLANATORY LANGUAGE