Loading...
HomeMy Public PortalAbout4825 CLOVERLY AVE_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING�1AQp p r ^V i-p(. or a certificate of Workers' Compensation Insurance,or a certified L4�I-IV�J 31/� l.W l copy thereof (Sec.3800, Lab.C.) CITY ZIP LOCALITY Policy No. Company SIZE OF LOT -'NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnishedNEAREST CROSS ST. ❑ Certified copy,is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS OWNER T L NO. , � CERTIFICATE OF EXEMPTION FROM WORKERS' f* S'�X S ,)rc WITHIN 1000 FT.OF SCHOOL? YES NO COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred ADDR S f- ��i /X ` ��� �%O \ DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100)or less.) / A CITY ZIP �- I certify that in the performance of the work for which this permit r, /�_ cJ �� �/ , is issued, I shall not employ any person in any manner so as toARCHITECT OR ENGINEER TEL NO. ✓✓✓ —���� become subject to the Workers'Compensation Laws. atm p-• try <11 j' ..g 3 STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS , (a' (� '! V CLASS NO. / DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate of e4- �� / ` ��� 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 FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION SIDE 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. ,T SIE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. OFQ® NEW ❑ BK PG , a License Number Lic.Class DESCR ©ION OF WOR ��Q ADD 1K VALUATION Q '®Z0•� v Contractor Date ALTER D D`. Off/ 11cc ElI am exempt under Sec. REPAIR El $ F- BAP.C. for this reason DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. URM ❑ CL /Signature APPLICANT(PRINT) TEL NO. LDMA Perm# z` Z ` I, as owner of the-property, or my employees with wages as 0 _ 1-w their sole compensation, will do the work and the structure is ADDRESS FINAL DATE ~ ^{ not intended or offered for sale (Section 7044, Business and / r _.L-I t Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ElI, as owner of the property, am exclusively contracting Wlth OAMOUNTSTURE SPEC FOEDTONI THE HAZARDOUSSMATER AILS INFORMATION GUIDE?ER THAN THEOR FINAL BY .. licensed contractors to construct the project (Section 7044, t aj i'{; _7 _r Business and Professions Code.) vEs F-1 No El = - Y WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDINGS'f OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH �.4''I"Ff j'•.3#_ - " CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKUST FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ NO❑ i Ii f!'3i -?ii Itis _ w the performance Of the Work for WI11Ch this permit IS ISSUed(SBC. (HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. !f N TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS '__,= 1 . - --• 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 o P.C.FEE PERMIT FEE of perjury that the above information is correct.I agree to comply o wi all county ordine and State laws relating to building l! a s �Upon ptabov�e- heronze r resentatives of this County ISSUANCE FEE m (O Qa co t nt rne for inspection purposes. a INVESTIGATION FEE TOTAL FEE D. m aJ r S mre o Aovi.cam ur Apenc V Dare SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT z COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL 1N BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS O�CJ or a certificate of Workers' Compensation Insurance,or a certified 2—,S- copy ^5copy thereof (Sec.3800, Lab. C.) - CIT C� zIP LOCALITY Policy No. Company SIZE OF LOT - NO.OF BL GS.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 Applicant ASSESSOR MAP BOOK PAGE4PARCELPp SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER C ���r6 YES NO COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? (This section need not be completed if the permit is for one hundred ADDRESS (i�— y 2 rl fill 11--,e � C/� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100)or less.) CITY i. /t e�T ZIP I certify that in the performance of the work for which this permit l-M � (_I r is issued, I shall not employ any person in any manner so as to ARCTE TOR ENGINEER TEL NO. !J become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ' ADDRESS CLASS NO.—01 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 FRONT comply with such provisions or this permit shall be deemed revoked. gDDRESS /���� LIC.NO. P L SIDE LICENSED CONTRACTORS DECLARATION CITYo^^ / LIC.CLASS P L I hereby affirm that I am licensed underprovisions,of Chapter 9 �'�� `�- l SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT. I NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW 1:1 BK PG ' CL DES PTIO F W RK ADD ❑ VALUATION Ip License Number Lic. Class � Contractor Date ALTER C1 $ fxf3 ElI am exempt under Sec. REPAIR $ BAP.C.for this reason DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. URM ❑ •, 0- Signature APPLICANT(PRINT) TEL NO. LDMA Perm# ❑ I, as owner of the property, or my employees with wages as Z lt_4•f,s their solecompensation, will do the work and the structure is ADDRESS -.O. 4 FINALD E ~ �'-I`�7F 1'7.4-§ not intended or offered for sale (Section 7044, Business and � r__ Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL T G � :3 +1�'[—' I, as owner of theproperty, am exclusive) contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 7, TOTAL I_I j i 3 �i e licensed contractors, to construct the project (Section 7044, i r AL 'rte a a'� ® 160- VES❑ NO❑ Business and Professions Code.) {� WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING Ivf�Es_ft OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR Q CHANGE alf f GUIDELINES. J !i!"N I hereby affirm that there is a construction lending agency for YES❑ No❑ 1 the performance Of the work for Which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING ©� , _ " '6' _ 3097, Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, 1 1,;1,11-0 I!3, --i� TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS ^ ' '• 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 P.C.FEE PERMIT FEE �/ O N with all county ordinances and State laws relating to building construction, and hereby authorize representatives of this County ISSUANCE FEE " t e ter upon t above-mentio d roperty for inspe on pyrposes. (O 7 a .�Jl�e CDj ��, INVESTIGATION FEE TOTAL FEE to miMature of Applicant or Data �/ SEE REVERSE FOR EXPLANATORY LANGUAGE