HomeMy Public PortalAbout9028 EMPEROR AVE_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES t_ a BUILDING AND SAFETY
y WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUIL&N DR S
I hereby affirm that I have a certificate of consent to self insure, "W'5
IH ING ADD ESS M R
or a certificate of Workers' Compensation Insurance,or a certified C O Zp
copy thereof (Sec.3800, Lab.C.) "I, _ IP
M t t Ir LOCALITY
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT C
❑ Certified copy is hereby furnished. NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
USE ZONE MAP N
department. O.
ASSESSOR MAP BOOK PAGE PARCEL 15-3 /1/1-�lo-
Date Applicant 7 0/1 1 SPECIAL CONDITIONS
CERTIFICWNER TEL NO.
ATE OF EXETON FROM W —
CO PENSATIONI NSURA CEORKERS' °mR N ��J !�/` O WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDRESS
)5/h PO/ e 1� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
90cd3 r �
dollars ($100)or less.) l Y�
CI Y ZIP
I certify that in the,performance of the work for which this permit 7 3
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. cJ
become subject to the Workers''Compensation
Laws. STATISTICAL CL SSIFICATION APT CONDO
Date G-fit;_93 Applicant 1C A(` 4 06 6' � O ADDRESS CLASS NO.� DWELL UNITS
NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you Should become subject t0 the Workers' NTRACTOR ,J TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith `( � C^ I� D �/�(D'�i(cZa FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L
LICENSED CONTRACTORS DECLARATION CI 3 Rio Nvlvdo 9C� '�1SIDE
- CTE LIC.CL S P L
I hereby affirm that I am licensed underprovisions of Chapter 9 — rn SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES
Professions Code, and my license is in full force andeffect. NEW El BK PG ► a
License Number��6 7 ^ic. Class DESCRIPTION OF WORK ADD ❑ VALUATION O
Contractor RA <t'N eA?' (*ate to '�!� ` O D/� ALTER W $ ' U
fi7"C N = JZI— o EG - 0
❑ I am exempt under Sec. (( REPAIR ❑ $
BAP.C.for this reason l.0 la.l Cd(Q)S OA/�U(j-fes DEMOL ❑ LDMA P/C# �JJ
ate: USE OF X;y�JTIN_GCB�LDG. n URM ❑ G'
Si a ut re r\ T) I E ` +^ TEL NO. LDMA Perm# ':' ' Z
9 I A T�j(PRINT) .` z
Sf 1" 0 Z i+t
❑ I, as owner oft property, r my employees with wages as /'F /4 0
their sole compensation, will do the work and the structure is ADDRESS ACCT.
r.��f- A ■r 8
not intended or offered for sale (Section 7044, Business and ( 3 Irto OAda 4 M cV 1 FINAL DATE Q
C' 50�
Professions Code.) ��' `''`'�`' 500. 't
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J
❑ I, as owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE {{
Y, Y 9 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BW
W 1
licensed contractors to construct the project (Section 7044,
Business and Professions Code.) YES❑ No❑ ht_4 AL.
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH X30�y3 �� �-:
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR JJ`i.lLt 438.3
GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ No❑ 2 ITEN
N the performance of the work for which this permit Is Issued(Sec. IHAVEREAD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING (� �* 3
3097, CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. TOTAL "B'8 V® -123
N 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. CHEIL. 1+ s�'
o Lender's AddressA t
O OWNER OR AGENT .. CHANGE .010
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.
o with all county ordinances and State laws relating to building (pd t 1 t
< construction, and hereby authorize representatives of this County ISSUANCE FEE IOI-�I�IJ 6/ 5/9'
M to ent theve ntiorop for i ection purposes.
n p . ._
INVESTIGATION FEE TOTAL FEE
114`9 1 AM u.4:
Sig--or i o1 nee,f Dare �
SEE REVERSE FOR EXPLANATORY LANGUAGE