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HomeMy Public PortalAbout9514 BLACKLEY ST_Building__ APPLICATION!- FOR BUILDING PERMIT r _,d► COUNTY OF LOS ANGELES BUILDING AND SAFETY yBUILDIN ADDRESS WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN I hereby affirm that I have a certificate of consent to self insure, BUILDIN DDRESS tic or a certificate of Workers' Compensation Insurance,or a certified copy thereJoff (Se .3$�Q10,La C.) I CITY /2•. ZIP LOCALITY Policy NO.r J�4� � Company & SIZE'OF LOT I NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. �C rtified copy is filed with the Ounty building in ecti0 TRACT BLOCK LOT NO. USE ZONE MAP NO. department. Date/ Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER�� C� TIVO, .s _0 l YES NO COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? (This section need not be completed if the permit is for one hundred ADDRESS -7(� �C G� DISTRICT GROUP TYP CONST. FIRE ZONE PROCESSED BY dollars(S 100)or less.) Y /` ZIP I certify that in the performance of the work for which this permit IR tz Ca k ( if ��� is issued, I shall not employ any person in any manner so as to100 ARCHITECT R ENGINEER TEL NO. become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION 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 t0 the Workers' T TQQR��/7I�� TEL 0. G. [ SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith U J i � !� Q-Gs ���bV ,-6q Z FRONT comply with such provisions or this permit shall be deemed revoked. ��D^^FF���S�g{ ��/�� LICNO. PL 1+� (�7 I V 1 6-D , SIDE LICENSED CONTRACTORS DECLARATION cl Q LIC.CL S P L I hereby affirm that I am licensed underprovisions of Chapter 9 vi �11�� / 7 — SO.FT.SIZE NO.OF STORIES NO.OF FAMILIES SEWER MAP (commencing with Section 7000)of Division 3 of the Business and NEW ❑ BK PG Professions�Codkienjdiylicense is in full force andeff ct.,License Nu �� Lic.Class Ci�� DESC Oro 1F'76 � Re I�� W.e�1 App ❑ �L/�D O` eL-v 0 Contractor _ Date i 7� ALTER ❑ ^ CIO%% A• CO 1'v1 J2 s IU� REPAIR ❑ $ El am exempt under Sec. B.&P.C.for this reason DEMOL ❑ LDMA P/C# III Date: USE OF EXISTING BLDG. URM ❑ y IL Signature AP,UyICANT(PRIN ) (� EL O. a �,3 LDMA Perm# - s z ❑ I, as owner of the property, or my employees with wages as `�1C7 C�r `�'�✓ iv Z I't= their sole compensation, will do the work and the structure is ADP(�ESSQ /� not intended or offered for sale (Section 7044, Business and I�OIJ�u '► �, . r Uo 037 FINAL DATE Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ❑ 1, as owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE -3 y g AMOUNTS SPECIFIED N THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BYJ S 1 4 � 3iu 4 licensed contractors to construct the project (Section 7044, YES❑ NO 4J 0' I �L �+� ,� .,;; -- n • Business and Professions Code.) HID, ; 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(SCAOMD)SEE PERMITTING CHECKLIST FOR ;_HNG` n%?I GUIDEUNES. CA I hereby affirm that there is a construction lending agency for YES❑ NOZ�� 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.C.) OHECKLI T. UNDERSTAND MY REOU E ENTS UN ER THE LOS ANGELES COUNTY CODE, y Ij I I#I-t t�' N TITLE 2, HAPTE .20 ECTIONS 2 00 THR 2.20.140 CONCERNING HAZARDOUS Lender's Name MATE I S REP IN N FOR G A FROM THE SCAQMD. -r j-ri -- CL Lender's Address OW ER OR AGENT O O I certify that I have read this application and state under penalty O of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE �� with all county ordinance and State laws relating to building con truction, and hereby ori ze presentatives of this County ISSUANCE FEE - to ter up th agave-m f ne perty for inspe tion purposes. �4 m / / —'7��ICf! INVESTIGATION FEE TOTAL FEE /© ? O 10 ° J Wre al AOO���nt or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE