HomeMy Public PortalAbout9038 CALLITA ST_Building__ APPUCAMON FOR BULL IG PERNT �l
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADD Ess
hereby affirm,that have a certificate Of consent to self insure,
BUILDING ADDRESS 001
or a certificate of Workers' Compensation Insurance,or a certified
copy the of 3800,Lab.C.) �,�.LH�'.�� v � ZI�,•7�� LOCALITY
Policy NO d`� g V+1 Company ` y SIZE OF LOT NO.OF BLDGS.NOW ON LOT
C1 Certified copy is hereby furnished. NEAREST CROSS ST.
1
fJ Certified copy is filed with the county building ir4 pection TRACT - BLOCK LOT NO.
depar ant. T l 1 USE ZONE MAP N0.
Date Applicant yw ASSESSOR MAP BOOK PAGE .PARCEL
_ SPECIAL CONDITIONS
C RTIFICATE OF EXEMPTION FROM WORKERS' ow No.
COMPENSATION INSURANCE �y 1-735- WITHIN 1000 Fr.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDRESS '
/Toy Z /1/-1 Q 1 DISTRICT GROUP PEG ONE PROCESSED By
dollars ($100)or less.) "T '
I certify that in the pert mance of the work for which this permit T ^ C�� )/y (a ZiO
is issued. I shall not em toy any person in any manner so as to f T c+ C �
become subject to the W kers Compensation Laws. ARCHITECT OR ENGINEER TEL NO.
P STATISTICAL CLqASS/IFKATION APT CONDO
Date Applies t ADDRESS CLASS NO.Ox / DWELL UNITS
NOTICE TO' APPLIC4NP , after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption_ you should become subject - t0 the Workers' CO�IT�AQTOR� c4'.,4
' •TTEk NO. SET BACK YARD HWV PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith J W c4' ass-81
1 LAIDFRONT
comply with such provisions or thispermit shall be deemed revoked. ADDRESS p f - IC. P L
LICENSED CONTRACTORS DECLARATION �8 S' S U-r, Y'L•C `3k"`-o&Z_ SIDE
CITY 1 LIC.G SS P L
I hereby affirm that I am licensed underprevisions of Chapter 9 So, Y' L e- ` e-2k-k SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORIES NO,OF FAMILIES
Professions Code,and my li ense is in full force and effect. NEW ❑ BK PG }
1 C-3 DESCRIPTION OF WOK ADD ❑ VALUATION d
License Number Z Lia Class � D CL
Contracto-4 +\ Date .9 ALTER ❑ $��`"� L)
❑ lam exempt under Sec. REPAIR $ HA
B.&P.C.for this reason m DEMOL ❑ U
LDMA P/C+~ UJ
Date: USE OF EXIST' LDG. URM ❑ .
Signature AP ICANTrNT) p} '7TELyry�0$(� LDMA Perm x 1 _ Z
❑ I,.as owner of the property, Or my employees with wages as �Y1�` (� `"�^'_" Z y��L'I 'T
their sole compensation, will do the work and the structure is ADDRESS 1/�_ Imo, Q O 77
not intended or Offered for sale (Section 7044, Business and ��� ` Sorvixv^`'r l�"I Y, FINAL D TE - Q '•r='07 '( ^
Professions Code.), - WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL s r, -O 1 1 [M
OR A MIXTURE CONI No A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
❑ I, en owner co of the property, am exclusively contracting 44, AMOUNTS SPECIFIF N THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 7 C
licensed contractors Profen to construct the project (Section 7044, YES❑ No TOTAL AL •.�J s `' '
Business and Professions Code.) H
WILL THE INTENDED USE MI THE CONSTRUCTION
BV THE APPLICANT OR FROM T BURRING L.a�El.{?A
OGCUPFNL REQUIRE A FERMIT.NT CONSTRUCTION IN EE PERMITTING
FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QunuTv M'..acEMEM DISTRICT IscnQMDI SEE PERMITTING cHECKUM FOR (HAN L I`I
GUIDELINES. l•rll'11'I'JL L
•I hereby affirm that there is a construction lending agency for YES El No
iN the performance Of the WOfk for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
3097, Civ.C.) CHECKUST,I UNDERSTAND MV REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, j �'}{ (1
TITLE 2,CHAPTER 2.20 SECTIONS 220.100 THROUGH 2.20.140 CONCERNING HAZARDOUS 0000-10 ,/1
Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
Lender's Address - 9530 1 010'23
Q O"ER M IgEM
o - I certify that I have read this application and state under penalty
4 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
with off county ordinances and State laws relating to building -
m construction, and hereby authorize representatives of this County ISSUANCE FEE /
1O to antpaupon t\abo' -yq mentioned property for inspection purposes. (O
� INVESTIGATION FEE TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE