HomeMy Public PortalAbout9939 BROADWAY_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN 7 BUILDING ADDRESS
I hereby affirm that I have a certificate Of consent to self insure, BUILDIqnE
or a certificate of Workers'Compensation Insurance,or a certified CITY ZIP gwaV
copy thereof(Sec.3800,Lab.C.) O
LOCALITY PLC C 1
Policy NO. 'Company SIZE OF LOT NO. FBLD SN ON LOT
C
RALOT
Z NEAREST CROSS ST.
❑ Certified copy is hereby furnished. x
❑ Certified copy is filed with the County building inspection TCT BLOCK 'L TNO.
department _ USEZONE MAP NO.
ASSESSOR MAP BOOK PAGE PARC L
Date Applicant - SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ' / TEL
NO.—�7�"
COMPENSATION INSURANCE J WITHIN 1000 Fr.OF SCHOOL?
YES NO
ADDRESS
(This section need not be completed if the permit is for one hundred DISTRICT GROUP' TYPE�CONST.' FIRE ZONE CESS BY
dollars(5700)or less.) CITY � CG .ZIP /7 0 S /�( - 1
I certify that in the performance of the work for which this permit U UVA rrt__„'Y/Milli
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO,
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT C O
Date Applicant ADDRESS CLASS NO, DWELL UNITS
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR TEL.NO. REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject t0 the Workers SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith
FRONT
Comply with such provisions or this permit shall betleemed revoked. ADDRESS LIC.NO.
PL
SIDE Y
LICENSED CONTRACTORS DECLARATION CITY W LIC.CLASS PL a
o
o
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP U
(commencing with Section 7000)of Division 3 of the Business and SO.FT SIZE NO.OF STORES NO.OF FAMILIES C
Professions Code,and my license is in full force and effect. NEW ❑ BK PG - ► t—
License Number LiC.Class DESCRIPTI NOF WORK .InnADD ❑ YAL TIO W
JW
vl JI a
Contractor Date ALTER ❑ $ �y z_
❑ I am exempt under Sec. REPAIR $ -
B.&P.C.for this reason DEMOL ❑ LDMA PIC k
Date. USE OF EXISTING BLDG. URM ❑
Signature APPLICA T IN • SEI,.NO. LDMA Perm k
❑ I, as owner of the property, or my employees with wages as O
their sole compensation, will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and / FIN ALD C 77-797 _IeG„�
Professions Code.) WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANTHANDLEA HAZARDOUSMATERIAL T{�IY
❑ 1, as owner of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q i TTENS
iO
Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to Construct the roject-Section 7044, J
Business and Professions Code.) project
( YES❑ No❑ TCIT FCL J� >mc__r
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING JOT V
OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION ORMODIFICATION FROMTHESOUTH f,',j GHE X �i-1e�v�
CONSTRUCTION LENDING AGENCY COAST AIR DUAL \_�y1✓i �( }�}
DUALITY MANAGEMENT DISTRICT SCAOMDt SEE PERMITTING CHECKLIST
GUIDELINES. CHANGE .00
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 SCAOMD
3097,Civ.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES r r l 'T r
Lender's Name COUNTY
CODE.TEUEZCHAPTER 2,0 ANOSECTIONS
z AWTHOUGH2FROM1HNCERNIAG. 0003-0001 (j 3194)
D
Lenders Address wNmaR Aewr - 1630 1 AIS 7:50
I forma chat have reed this application and state that the above P.C.FEE PERMIT F /L
information is correct. I agree to comply with all county 'f -
ordinances and State laws relating to building construction,and
hereby authorize representatives of this County to enter upon ISSUAN
thel�n pr erry for inspection purpos
< INVESTIGATION FEE TOTAL FEE
SEE REVERSE FOR EXPLANATORY UAGE