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Home My Public Portal About4502 FIESTA AVE_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES v i BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADD SS I hereby affirm that I have a certificate of consent to self insure, BUIyG;DESS / or a certificate of Workers' Compensation Insurance,or a certified /�(! copy thereof (Sec.3800,Lab.C.) ZIP9l 7 LOCALITY Policy No. Company SIZE LO'F►, T NO.OF BLDGS.NOW ON LOT �7✓ ❑ Certified copy is hereby furnished., NEAREST CROSS 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 SPECIALCONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' Q � ,�-3 >r0 / COMPENSATION INSURANCE '/7 WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred AD ghSS dollars ($100)or less.) #J 0,� V DISTRICT GROUP TY ONST. FIRE ZONE PROCESSED BY certify that in the performance of the work for which this permit CIT ` ZIP / is issued, I Shall not employ any person in any manner SO as t0 gRCHI�ECT REENGINEER T/EL NO. ': , become Subject t0 the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. 4:;?/ DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you- Should become Subject t0 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. PL } LICENSED CONTRACTORS DECLARATION SIDE CITY CITY LIC.CLASS PL 1 hereby affirm that I am licensed underprovisions of Chapter 9 U (commencing with Section 7000)of Division 3 of the Business and SEWER MAP T.SIZE NO.OF�STORIES NO.OF FAMILIES � Professions Code,and my license is in full force and effect.5 NEW BK PG O License Number Lic.Class DESCRIPTI OF WORK ADD ❑ VALUATION , r) Contractor Date l ALTER El $ " CL 00 ' ❑ I am exempt under Sec. REPAIR ❑ $ Z BAP.C.for this reason I DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. V URM Cl Signature � � APPLIC (PRZNT j7 TE O. LDMA Perm a 3 31013 . 3 �t �_�? i58 :8c I, as owner of the property, or my employees with wages as �Ln Z 1:1J e Lt•_F '+Ias sole compensation, will do the work and the structure is ADDRE /;nAn B 0 2 1 i TprIM� not intended Or offered for sale (Section 7044, Business and c>w'/ , l V FINAL DATE Q 1 C Professions Code.) f / TOT � WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL �(ati�"i� J ( ._8;„y y_•y��g ❑ I, as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL.TO OR GREATER THAN THE (� AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY D'.Ei � licensed contractors to construct the project (Section 7044, .1..,LID YES❑ NO❑ CHANGE __ Business and Professions Code) l.L (; WILL THE INTENDED USE OF THE BUIDLING BV THE APPLICANT OR FUTURE BUILDING • n{JI j OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. - �} I hereby affirm that there is a construction lending agency for YES El NO❑ 00cloi001 4/22/96 /96 the performance Of the Work for which this permit Is issued(Sec. (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, X991 1 AN 8:002 TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS m Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. m Lender's Address CIE OWNER OR AGENT 3 1 certify that I have read this application and state underpenalty p of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE ro with all county ordinan es.�an��State laws relating to building co r tion, and hereb autrepresentatives ofJi,.n his C unty ISSUANCE FEE toen,a pon abov entiproperty for inspec pur o e .�'' INVESTIGATION FEE TOTAL FEECq �9, re at Apphcant w Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE ! � y�`NORKERS'COMPENSATION DECLARATION f� ipso reby a` certificate that I have r certificate of consent to self APPLICATION FOR BUIL®I N G �P t RM I T ,ILJII iDsure, ora certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) s✓ „- COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company � BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESSC�i Certified copy is filed with the county building inspec- BUILDING 75� -- p T- tion department. ADDRESS -; '��+ ti y� ,C Date 7'"/ � �Applicant ICoo -= y CITY 2 1`ZcG ',`G ZIP ; LOCALITY ' CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT ; �, NOW ON LOTS.' "'. NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the permit is for one """ ASSESSOR hundred dollars ($100)or less.) TRACT (`. BLOCK LOT NO. MAP BOOK PARCEL TEL. US ZONE MAP I certify, that in the performance of the work for which this OWNER y-- / NO. & 7 NO. permit is issued, I shall riot employ any person in any manner ADDRESS /—��3 � CONDITIONS a SPECIAL so as to become subject to the Workers',Compensation Laws. zU , Date Applicant CITY �;/ �Zv C° ZIP. NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GR UP TYPE FIRE I PROCESSED BY 0 E ZO I" Exemption,, you should become subject to the Workers' � ENGINEER NO. CONST. U Compensation provisions of the Labor Code, you must'forth- ADDRESS -3E W. with comply with such provisions or this permit shall be TE lrs/ r STATISTICAL CLASSIFICATION APT. L )0, N t deemed revoked. CONTRACTORON � '�A Z N LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. 2. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS/4_"/y -' ,ri` NO. 7` � (commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP Professions Code, and my-license is in full force and effect. CITY CLASS 77 / BK PGVALIDATION .i SO. FT %� NO.OF A NO. OF CHECK License Number _`� Lic.Class SIZE B/ STORIES ( FAMILIES ONE a^T. r'''�yyy�� 9 ❑ VALUATION Coniractor� '"� ' r"�-� Date r"�' DESCRIPTION OF NEW 4 4 $ t 9 5 9,0 A C�y>fl� /�Gc �/ i ADD . I am exempt under Sec. � ALTER # o 0 0 0 0 J B.BP.C. for this reason 1-gle-1117 9 �d REPAIR USE OF ,✓ 10209,25 Date: EXISTING BLDG. / l DEMOL APPLICANT y� /�/� 'TEL./� f o 0 Signature ZZ PRINT ' /= Cl ee�s�j N07 FINAL 2 0 9,2 5:� OWNER-BUILDER DECLARATION DATE ' I hereby affirm that I am exempt.from the Contractor's License �j9� )t-"�� FIN 5 2,� Law for the following reason (Section 7031.5, Business and ADDRESS 88. Professions Code): PRESENT B E] BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and z. the structure is not intended or offered for sale(Section LOCALITY I 7044, Business and Professions Code). MOVING TEL I, as owner of the property, am exclusively contracting CONTRACTOR NO. a c with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAREQUIRED PROP.pCK L NEFROM 4W1DTk I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name m P.C. fee$ Permit Fee I L S LDMA Ref. M Lender's Address I certifythat I have read this application and state that the ` t PP Issuance Fee S� LDMA'P%Clq' above information is correct. I agree to comply with all County Investigation Fee o. ordinances and State laws relating to building construction, Total Fee /I ./ J LDMA Perm.. `r R and hereby authorize representatives of this County to enter m upon the above-mentioned property for inspection purposes. ' t 1 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Appi icani or Agent Date 4 i' I t,-