HomeMy Public PortalAbout5448 ENCINITA AVE_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES - 'BUILDING AND SAFETY
a
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self Insure, BUILDIN D S IV
or a certificate of Workers Compensation Insurance or a certified
a zP '
copy thereof (Sec 3800,`Lab C) _ LOCALITY ,
Policy No Company SIZE OF L T NO OF BLDGS NOW ON LOT G
NEAREST CROSS
El Certified copy is hereby furnished T a ^
❑ Certified copy Is•filed with the county building Inspection TRACT BLOCK LOT NO
department USE ZONE MAP NO
ASSESSOR MAP BOOK PAGE -PARCEL �- t
Date Applicant SPECIAL CONDITIONS,
CERTIFICATE OF EXEMPTION FROM WORKERS' O T o Q�
COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? YES NO
(This section need not be completed If the permit Is for one hundred ADDRESS eI
dollars ($100)or less) I N DISTRICT GROUP T CONST FIRE ZONE PROCESSED BY
CIT � ZIP /^�
I certify that in the performance of the work for which this permitlem CA
Ae ` �l /� D�p _ /r f
IS Issued, I shall not employ any person in any manner SO as to, ARCHIT T OR ENGI EER TEL NO 16
become subject to the Workers CompensationLaws r� STATISTICAL CLASSIFICATION APT CONDO
Date_ Applicant l .ti, - ' $�3b� ADDRESS CLASS NO DWELL UNIT
NOTICE TO APPLICANT If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers C NTR TO _ T O n 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 DRESS LI O D P L
SIDE
LICENSED CONTRACTORS DECLARATION c1T Llc P L
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Dlvision,3 of the Business and SQ FT SIZE NO OF STORIES NO OF FAMILIES
Professions Code,and my license Is In full force an fect ' NEW BK PG , d
License Number Lic ClBS DESCRIPT N OF WO K /w O� ADD ElVALUATION Q
lbContractor Date t Y I 1`H ALTER ❑ $
El am exempt under Sec REPAIR El $ 0
BBPC for this reason DEMOL ❑ LDMA P/C# W
Date USE OF EXISTING BLDGURM a ❑
Signature APPLICANT(PRINT) TEL NO LDMA Perm# 1 Z
El 1, as owner of the property, or my employees with wages as
their sole compensation will do the work and the structure Is ADDRESS
not Intended or offered for sale (Section 7044, Business and FINAL DATE
Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ( ✓� - i I1
❑ I, as owner of the property, am exclusive) contracting Wlth OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
P P Y. y 9 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project (Section 7044, YES❑ NO❑ z T`-I.HL I-01-5�® 0
Business and Professions Code)
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING Ilk {p
hEY t'Ile s
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH - '- -
CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES _ '-I-I�(�i3'[ it S
1 hereby affirm that there Is a construction lending agency for YES❑ No❑ - -- -
N the performance of the work for which this permit is Issued(Sec I 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 - _ +• —
a TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS
3 Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD _
IL 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 PC FEE PERMIT FEE
with all county ordinances and State laws relating to building
m construction, and hereby authorize representatives of this County ISSUANCE FEE �f/
cot ter upo e abo v -mentioned property for Inspection purposes T �i
,Q INVESTIGATION FEE TOTAL FEEID
Sw to w Appkwt a m Date
SEE REVERSE FOR EXPLANATORY LANGUAGE