Loading...
HomeMy Public PortalAbout5957 ENCINITA AVE_Building__ % 2$-�-,coati APPUC AMON FOR BU L�©ING f�l�RNT COUNTY OF LOS ANGELES ; BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT 70 FILL INBUILDING ADDRESS. � � I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS Or a certificate of Workers'Compensation Insurance, or a certified bl Ea61ilT III copy thereof(Sec.3800,lab.C.) CITY' ZIP p. T rLe G 1 `1�1"��1 OCALITY Policy NO. Company 'SIZE OF LOT •` ' NO.OF BLDGS.NOW ON LOT • [2 Certified copy is hereby furnished. -&0 X •W5 NEAREST CROS ST. II ❑ Certified copy is filed with the county building inspection TRACT. BLOCK • LOT'N0.' - - ' USE ZONE MAP NO department. . Date Applicant ASSESSOR MAP 1300K PAG EE PARCEL SPECIAL CONDITIONS OWNER TEL NO. (' CERTIFICATE OF EXEMPTION FROM WORKERS' ` - COMPENSATION INSURANCE Ef.T C101 h -TfL.-7 JL('} Z.$`'. j'3,;1,&-7 WITHIN-1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS 2 dollars($100)or less.) 7JY/ ' 6, �ra'�._' I'Z- DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY CI ZIP I certify that in the performance of the work for which this permit 1-7-7 t7 is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. vRCH♦I�TECT OR ENGINEER - eTEL NO. _ F _ 3 STATISTICAL CLA IFI TION / APT CONDO' DateApplicant ADDRESS CLASSNO. (� DWELL UNITS TICE NOTO APPLICANT. If, after making this Certificate of 221 G a• c�+u P3aa tZ o REQUIRED' TOTAL SETBACK FROM EXIST Exemption, you should become subject t0 the Workers' CONTRACTORT ^'� TEL NO, SETBACK YARD HWV .PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith tl`^+^�'- FRONT _ comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO, PL y _ LICENSED CONTRACTORS DECLARATION SIDE h6_�_i .Tr - CITY LIC.CLASS 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 SO FTq,SIZE N0,OF STORIES NO.OF AMILIES ` d Professions Code,and my license is in full force and effect. �J' lr7l� NEW BK - PG i ITENCi p License Number Lic.Class CD D SCRIPTIOI�OF WORK ) ADD ❑ VALUATION > I i�iiL' > 13 Contractor Date ALTER ❑ $ a Z-`D' UI tat)r?=,t.}i ❑ I am exempt under Sec. REPAIR ❑ z BAP.C. for this reason rte,~ G •,S DEMOL ❑ LOMA PIC x, ' Date: USE OF EXISTING BLDG, L4`A�1 URM ❑ - r/"• ` e\ 1 j iT`''_;_FI=_IFI) Z ']f',-:_ Signature ICANT(PRINT) TEL NO LDMA Perm A 1 i _ `� CT17.I ' �} ...�, l t A x17111 _!_; ❑.I,as owner of the property. or my employees with wages as T E'As� �c DID Sb�" u",14x' �', I Z -.I'1 4 their sole compensation, will do the work and the structure is ADDRESS (� O + 1-�ri-i-ti - FINAL DATE` i \ not intended or offered for sale (Section 7044, Business and �V ti 1Tc3z�'T 4 A � - lL,...,��'Professions Code.) `MLL THE APPUCANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL -N A Aro I, as owner of theOe yro rt : am exclusively contracting lusive) tts With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE P AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL B .T 1 ;:ryf'1 +•+ licensed contractors to construct the project (Section 7044, •�-. I_ (j(�q(• �7!S; YES C1 NO WILL THE TEA Business and Professions Code.) - N/ INIRE USERMI THE BUIDLINGCONSTRUCTION BY THE APPLICANT OR FUTURE EBUILDING SOUTH i'i OCCUPANT REQUIRE A PERMIT FOR L TRICT CTION OR EE PERMITTING FROM THE SOUTH I t;I t\\ I Ir'vl? COAST AIR pUAUTV MANAGEMENT DISTRICT ISCAOMDI SEE PERMITTING CHECKLIST FOR CONSTRUCTION LENDING AGENCY GVIDEUNES I hereby affirm that there is a construction lending agency for 'YES❑ Noy, m the performance of the work for which this permit is issued(See. HAVE READ THE(AZARDCUS MATERIALS INFORMATIONGUIOE AND THE SCAOMD PERMITTING 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, N TTTLI 2 20 SECTIONS 2.20.100 THROUGH 220.140 CONCERNING HAZARDOUS Lender's Name RIPLS R ANDFOP OBTAINING A PERMIT FROM THE SCAOMD Lender's Address ry j ntI1 a~ 0 ax<R M 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 ��O PERMIT FEE n with all county ordinances and State laws relating to building f+ / m construction, and hereby authorize representatives of this County ISSUANCE FEE - ^ n r upon theabove-mentionedproperty for inspection purposes. of I�OJ 7 wry �s=kA+�� LL� INVESTIGATION FEE TOTAL FEE q /. / 0C;l SEE REVERSE FOR EXPLANATORY LANGUAGE APPUCAMON F®R .BULMNG PERNT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN ESS BUI DING ADDRESS _ hereby affirm that have a certificate of consent to self insure, � S '('„�N LT A or a certificate of Workers' Compensation Insurance,Or a Certified Copy thereof(Sec.3800,Lab,C.) GrgEil�PL-- LOCALITY ZIP f C-(Tl Policy N0. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST GROSS 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 O ? D� ✓ SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNEH TEL NO. YES NO COMPENSATION INSURANCE JLTIIa. TAW"-r .WITHIN moo FT of SCHOOL? (This section need not be completed if the permit is for one hundred A RESS Z3 i 1k DISTRICT GROUP TYPE CONST. FIRE ZONE .PROCESSED BY dollars IS 100) or less.) ' 1 certify that in the performance of the work for which this permit - -(C^� Z (�•� �G7� _ ? n Lie J is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO - J y/ become su IeC t e Workers' mpensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS - CLASS NO. �q DWELL UNITS NOTICE TO APPLICANT: If, after making this Certificate of REQUIRED TOTAL SETBACK FROM E%IST Exemption, you Should become subject- t0 the Workers' CONTRACTOR � � � J TEL NO. - SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith G�f FRONT comply with such provisions or this permit Shall be deemed revoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATIONSIDE 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 SO.FT.SIZE NO.OF STORIES NO.OF FAMILIES - Professions Code,and my license is in full force and effect. [EPA BK PG D d License Number Lic. Class DESCRIPTION OF WORK 0- VALUATION �/ O Contractor Date DD I Tf .SAL 5J ❑ $ ��Q U ❑ 1 am exempt under Sec. ❑ 1$ B.BP.C. for this reason ❑ LDMA P/C s - O WDate: qF,� ING BLDG. ❑ nn1'� Signature APPLICANT(PMW) TEL NO. LDMA Perm♦ nf_f�{ e g ' Z ❑ 1, as owner of the property, or my employees with wages as 6L^-)^r" Q -_I�` 1-77.Vii_ 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 'J - o i 1ltl 1. Professions Code.) HALL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL � � _ ❑ I, as owner of the OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EOUAL TO OR GREATER THAN THE Q property, am exclusively contracting with AMOUNTS SPECIFIES"THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL Y ] "TATAL d 77 v a licensed contractors to construct the project (Section 7044, vas❑ rvoTJ Business and Professions Code.) WILLt �_NEf=K. ir7.�_ OCC THE INTENDED USE OF THE B IDUNGCONSTRUCTION BY THE MODIFICATION OR FROM T BUILDING SOUTH ` _J{ OOASTA IR REQUIRE A PERMIT FOR L TRICT GTION OR EE PERMITTING FROM THE SOUTH t ,1j1h�tJL •t1fJ CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)BEE PERMITTING CHECKLIST FOR GUIDELINES I hereby affirm that there is a construction lending agency for res❑ N _ the performance of the work for which this permit is issued(Sec. m IHAVE READ THE HAZARDOUS MATERIALS INFORMATIONGNDEAND THE SCAOMDPERMITTING flilttil- IIJ,Jt y/ y/,r. 3097,Civ.C.) CHECKUST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. TRUE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.Ia0 CONCERNING HAZARDOUS { { { { Lender's Name --A - `� MATF}R�'a RE ii-PQR1JG AND FOR OBTAINING A PERMIT FROM THE SCAOMD. !f�l l 1 1,i i li+:`1 o Lender's Address /EA1^�=�n{D/E-�m��/•_- 0 0 1 certify that I have read this application and state under penalty pC.FEE PERMIT FEE w /� perjury that the above information t correct. agree to comply �D N with all county ordinances and State laws relating to building - m constrigIpten, and hereby authorize representatives of this County ISSUANCE FEE G to a upon jhp v -mentioned property for inspec,I yyJposes o < I/L �W//[yQL INVESTIGATION FEE - TOTAL FEEd Q / u o SEE REVERSE FOR EXPLANATORY LANGUAGE