HomeMy Public PortalAbout9432 EMPEROR AVE_Building__ APPLICATION FOR BUILDING 'PERMIT
COUNTY OF LOS ANGELES - BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BI �
BUIL DIy,G D RESS
1 hereby affirm that I have a certificate of consent to self Insure,
or a certificate of Workers Compensation Insurance,or a certified qM
copy thereof (Sec 3800 Lab C) CI p ZIP
Policy NO Company `� LOCALITY
SIZE OF L NO OF BLDGS NOWON 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 N
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' ow TEL NO
COMPENSATION INSURANCE WITHIN 1000 FT OF sCHOOL9 YES No
(This section need not be completed If the permit Is for one hundred
�
Is Issued, I shall not employApe In ny manner s0 as t0 q CHITECT OR ENGIN ER TEL NObecome subject the Worksat n STATISTICAL CLASSIFICATION APT CONDO
Date pphcanADDRESS CLASS NO DWELL UNITS
NOTICE TO APPLICANT Iking this Ce Irate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you Should become subject t0 the Workers CQ�I78A OR TEL NQ, SET BACK YARD HWY PROP LINE WIDTH
15
Compensation provisions,of the Labor Code, you must forthwith !.!1 O , 31D�6 33 1 FRONT
comply with such provisions or this permit shall be deemed revoked, A S Q LIQ-NO PL
LICENSED CONTRACTORS DECLARATION � •IC SIDE
ClCI Y r LIC LAS PL
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 SIZE NO OF TORIES NO OF FPMILI /y� 2
Professions Code,and m tic rise Is In full force and of ct NEW ❑ BK ��/ PG 7
a
DE CRIPT N OF WORK qpp ❑ VALUATION
License Nu er
LC
Class 1 I 0
Contractor to Z—a=%— ALTER ❑ $ ��
❑ I am a mpcc
t under Sec
^� UQ� h REPAIR ❑ OO
B&P C for this reason
DEMOL ❑ LDMA P/C# W
Date USE OF ISTING BLD - URM ❑ �-
Signature A PLI (PRINT) TEL NPf� _ LDMA Perm# ` z
El 1, as owner of the property or my employees with wages as d'h 7 Z ttV�T o i
their sole compensation, will do the work and the structure Is AD E S O
not Intended or offered for sale (Section 7044, Business and FINAL DATE Q ,j yi]� 111-.63 J
Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL M i
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J i ITEMS
❑ I as owner of the property, am exclusively contracting with AMOUNTS SPECIFIEN THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY rUTI7L A� .9-9
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licensed contractors t0 construct the project (Section 7044, YES 1:1 NO 1 +'�
Business and Professions Code)
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING CASH 113.63 i 3r.L,�_
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH `1'1711 + vrJ
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR '��
GUIDELINES 1 / C HAKE
I hereby affirm that there Is a construction lending agency for YES 1-1No Y;J�(
N the performance of the work for which this permit Is Issued(Sec I HAVE READT
HE HAZA US MAT ALS INFORMATION GUIDE AND THE SCAQMD PERMITTING _
3097,CIV C) CHECKLIST UN ER A D MY Q IREMENT DER HE LOS ANGELES COUNTY CODE
TITLE 2 CHAP T 2 0 CTIO 2 2 20 140 CONCERNING HAZARDOUS 0000-0001 2, 7,9`
Lenders Name MATERIALS RE T AND FO TAINI A RMIT F OM THE SCAQMD -
o Lenders Address 19$7 1 Ah110:J?
O OWNER ORAGg
oI certify that I have read this application and state under penalty
0 of perjury that the above Information IS correct I agree to comply PC FEE PERMIT FEE
with all county ordinances and State laws relating to building
co tru o , and ereby author) a representatives of this County ISSUANCE FEE
to er n the ove�a t erty for Ins 'ctlon p r ses
nC INVESTIGATION FEE TOTAL FEE
re d AP w om bade _
SEE REVERSE FOR EXPLANATORY LANGUAGE