HomeMy Public PortalAbout9673 BLACKLEY ST_Building__ � w - - ."..APPLICATION FOR BUILDING PERMIT
COUNTY-OF LOS ANGELES'. - BUILDING AND SAFETY-
WORKER'S COMPENSATION DECLARATION : FOR APPLICANT TO FILL IN G, B D G DRESS
I hereby affirm that I have a certificate of consent to self Insure, BUI `INIG AD ESS
or a certificate of Workers' Compensation Insurance,or.a certified `a C
copy thereof I(Sec'3 00,Lab C) �I / / /9 D
� (,� f D LOCALITY
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yNO. �Gompany SIZE OF LCT NO OF BLDGS NOW ON LOT Certified copy'Is hereby furnished. NEAREST CROSS ST
❑.Certified copy is filed with,the county building Inspection.•` TRACT BLOCK LOT NO
department � - USE ZONE MAP NO-
Date�'Appllcant, ! (M ^1.�_ �' ASSESSOR MAP'BOOK PAGE PARCEL
s 'SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM,WORKERS" NER TE NO L/
COMPENSATION INSURANCE • , L(�2— WITHIN 1000 FT OF SCHOOL" YES NO
(This section need not be completed If the permit is for one hundredA R S DISTRICT GROUP TYP ONST FIRE ZONE PROCESSED BY
dollars($100)or less.) � (�J ZIP 1_ u- -
I certify that In the performance of the work for which this permit is issued, I shall not employ any person In any manner so'as to' ARCHITECT ENGINEER TEL NOloo
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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 to the Workers' C CTO TEL NO` ,SET BACK YARD HWY PROP LINE WIDTH ,
Compensation provisions'of the Labor Code, you must'forthwltfi" Gi FRONT
comply with such provisions or this permit shall be deemed revoked A DRE S. C NO. P L >-
0.
LICENSED CONTRACTORS DECLARATION ITY� t- , d - 38g �fi SIDE O
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hereby affirm that I am licensed underprovlslons of Chapter 9 ^ SEWER MAP EU
(commencing with Section 7000)of Division 3 of the Business d SQ FT SIZE. NO.OF STORIE7 NO OF FAMILIES
Professions'Code,and my lice se Is In full force and effectNEW ❑ BK PG O
' CRIPTION OF WORK - ADD •❑ VALUA ON �> , ,U
License Number",A- Class — $7�/ " w
Contractor l�Date 'L^�Z^4 9' II ALTER - ❑ (p
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❑ I am exempt under Sec REPAIR ❑ $ Z
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BAPC for this reason (^ EMOL -13LDMA P/C# e
Date. USE OF EXISTING BLO9. URM ❑ ACCT;a
SignatureAPPLICANT(PRINT) TEL NO LDMA Perm# JG� 122.
❑ I; as owner of the property, or'my employees with wages as Z - ,
their sole compensation, will do the work and the structure Is ADDRESS O ,1 1TENS
not Intended or offered for sale'(Section 7044, Business and FINAL DATE Q ,.
Professions Code) Q� �a o TOTAL l_ - e I
-- WILL THE APPLICANT OR.FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL .[ ` J -
❑ I, as Owner of the property, am exci6slvel contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE. FINAL,BY
{,��{'�•` 122.20
P P Y. Y 9 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE'
licensed contractors to construct the project (Section 7044,• YES❑' NO❑ C.H�NGE
.00
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(SCAOMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES
1 hereby affirm that there is a construction lending agency for YES❑ No C3 1300�I—�Il��i 1 •P[f 17�gI�1
the performance Of the work for which this permit IS Issued(Sec. IHAVE READTHE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 4813 12:1 t
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 -
m Lender's,Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD
Lender-'s Address
OWNER OR AGENT
3 I certify that I have read this ppllcatlon and state under penalty
a PC FEE . - PERMIT FEE - -
0 of perjury that the above in ation Is correct I agree to comply
rn with all county or anc and State laws relating to building
m construction, reby horize representatives of this County ISSUANCE FEE
p� e n th oSe- Honed property for Inspection purposes.
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c Z_I INVESTIGATION FEE TOTAL FEE,/,,
N �Sq a Aoqwm a Agent Date - S O[
SEE REVERSE-FOR EXPLANATORY LANGUAGE