HomeMy Public PortalAbout5717 PRIMROSE AVE_Building_8/10/1995_REPLACE WINDOWS JW
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES ., r PUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION
FOR APPLILCANT TO FILL IN BUILDING ADDRESS IP I
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 5-7/ Q(•- S�� 7
copy thereof(Sec.3800,Lab.C.)
CIT �L� n'7 I?/7(f7O LOCALITY
Policy No. Company SIZE OF LOT �/ NO.OF BLD/GS NOW ON LOT
❑ Certified copy is hereby furnished. 430d -1—) / NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department.
USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PACE PARCEL
SPECIAL CONDITIONS 7�
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNERI,yg T °
WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred ADDRESS
P P
dollars($100)or less.) DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
CITY ZIP
I certify that in the performance of the work for which this permit _ 41 POP
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO `' v
become subject to the Workers'Compensation Laws. STATISTICAL CLNSSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. �� DWELL UNITS
NOTICE TO APPLICANT.- If, after making this Certificate of REQUIRED TOTAL SETBACK FROM 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 tovowO/�►�// Je FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL
LICENSED CONTRACTORS DECLARATIONSIDE
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 El BK PG , a
License Number Lic.Class DESCRIPTIONOF WORK IYI�NGOh�' ADD ❑ VALUATIONM O
Contractor Date ALTER Q" $ VV Q
El am exempt under Sec. REPAIR
El
BAP.C.for this reason DEMOL ❑ V
LDrAA P,C # W
Date: USE OF EXISTING BLDG. URM ❑ a
LL^..9A Prrrn Z
,Er", as owner of the property, or my employees with wages as Z
Signature APPLICANT(PRINT) TEL NO.
their sole compensation, will do the work and the structure is ADDRESS 0
not intended or offered for sale (Section 7044, Business and FINAL DATE / Q
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL �. 2
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J
❑ 1, as Owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY j
licensed contractors to construct the project (Section 7044, YES❑ NO❑
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDEUNES.
I hereby affirm that there is a construction lending agency for YES❑ NO❑
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.C.) CHECKLIST 1 UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
TITLE 2,CHAPTER 2.20 SECTIONS 2.20 100 THROUGH 2.20.140 CONCERNING HAZARDOUS
3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
o Lender's Address
OWNER OR AGENT
O
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 PC.FEE PERMIT FEE
civ with all county ordinances and State laws relating to building
construction, and hereb u e esentatives of this County ISSUANCE FEEco
yid
to ente he ab mentio per for inspe Ion purpo§es.
W INVESTIGATION FEE TOTAL FEE
r 3gnature M r A.i.. Dete L�O
SEE REVERSE FOR EXPLANATORY LANGUAGE