HomeMy Public PortalAbout4447 ELLIS LN_Building_2/12/1993_ APPUCAMON FOR SULUNG 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 ADDRESS
or,a certificate of Workers' Compensation Insurance,or a certified
copy thereof(Sec.38,00,'Lab.C.) CITY ZIP
Q"' LOCALITY. -
Policy No. Company - SIZE:OF C + - ki NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CROSS ST.
ElCertified copy is.filed with.the county•building inspection TRACT BLOCK LOT NO.
department.- g USE ZONE MAP N0.• .
Date A licant ASSESSOR MAP BOOK PAGE PAR - -
PP SPECT ONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO: YES NO
COMPENSATION INSURANCE $ H $ WITHIN 1000 FT.of SCHOOL?
(This section need not be completed if the permit is for one hundred ADDRESS '
.DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100)or less.)
- � CITY ZIP p� -
I certify that in'the performance of the.work for which this permit .. d
is issued, I shall not`employ any'persori in any manner so as t0 ARCHITEC R ENGINEER TEL NO.
become subject to the Workers'Compensation Laws. STATISTICAL CL�ASIFICATIO ''�� APT CONDO
Date Applicant ADDRESS -,CLASS NO. C--W/ ELL-TJNfTS -
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. ADDRESS LIC.NO. 'P L
SIDE
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PL
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3Of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES
:Professions Code,and my license is in full force and effect. NEW ❑ BK PG
License Number. Lic. Class D d
DESCRIPTION OF WORK -ADD VALUATION '
$ U �J _. .. —
��
Contractor Date ALTER O 6OJ. f1 -c
REPAIR El ITEMS
i E _
El '
I am exempt under Sec. $ 1� 5 U
e.&P,C.for this reason DEMOL 13 LDMA P7C'# �I
I
-USE OF EXISTING BLDG. 13 _ aa:-.f fl
Date: URM ❑-.
Ignature APPLICANT(PRINT) TEL NO. LDMA Perm# _ '.00 Z
� �lfi3
f'
I, as owner of the property, or my employees with wages as 0
their sole compensation, will do.the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DATE Q _II 130-01001 2/1219
PfOfeSSIOr1S Code.) WILL THE APPLICANTORFUTURE BUILDING OCCUPANT HANDLE A H ARDOUS MATERIAL + Z '' h i'a
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE _ _ _ J {' ° ='
V 11
❑ I, as owner of the property, am exclusively contracting with AMOUNTS SPECIF�I O ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY --
licensed contractors to construct the project (Section 7044, YES 11No�I
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 Aw QUAUTY M,.KAGEMENT'DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES. ,❑'E//
I hereby affirm that there is a construction lending agency for El NO
a the performance Of the Work for which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
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
3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
o Lender's Address
OWNER OR AGENT -
O
o ° I certify.that I have read this application and state under penalty
Of perjury that the above information is correct.I agree to comply P.C.FEE f N� PERMIT FEE jO ���
W ith all county ordinances.-and State laws relating to building Z.
construction, and hereby authorize representatives of this County - ISSUANCE FEE
00
to enter up e above- onEd property for inspection pur oses.
INVESTIGATION FEE TOTAL FEE 9 3 s O
D /Sgnatur icanl or Agenl Date �
SEE REVERSE FOR EXPLANATORY LANGUAGE