HomeMy Public PortalAbout4817 FIESTA AVE_Building__ APPLICATION FOR BUNDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self insure, BUILDIV �I Es 779 /�/r �P
or a certificate of Workers' Compensation Insurance,or a certified '/ "
copy thereof(Sec.3800,Lab.C.) CITY - ZIP ZIP �/ �� �l LOCALITY
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
El Certified copy is hereby furnished. 4 S x NEAREST CROS T. 100,
❑ Certified copy is filed with the County building inspection TRACT BLOCK LOT NO.
department. / q-- { USE ZONE MAP NO.
Date Applicant ASSESSOR MAP 900K PAGE PARCEL _
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNE ����� TEL fy�o.
COMPENSATION INSURANCE C;„ \ {: /' WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDR
1 S DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100) or less.)
I certify that in the performance of the work for which this permit CIT 1rol t el
ZIP ell 78 P �D ,•
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. u�f /q`�
become subject to the Workers'Compensation Laws. a= STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. C�g I DWELL UNITS
NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become Subject to the Workers' CONTRACTOR ��++ TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith ! � P G fZ-
FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS .--, LIC.NO. p L
LICENSED CONTRACTORS DECLARATION `�— SIDE
CITY LIC.CLAS P L
I hereby affirm that I am licensed underprovisions of Chapter 9
(commencing with Section 7000)of Division 3 Of the Business and SQ.FT.SIZE NO.OF/TORIES NO.OJ FAMILIES SEWER MAP
Professions Code,and my license is in full force and effect. NEW BK PG 0-
License Number Lic.Class DESCRIPTION OF WORKADD EJ VALUATION , O
Contractor Date / S r*4 L S K _L16/11 ALTER ❑ $ / V
❑ I am exempt under Sec. REPAIR ❑ $ 0
B.&P.C. for this reason DEMOL ❑ LDMA P/C# W
Date: USE OF E G LDG URM ❑ D-
Sigature /�r /�� U)
Signature_ APPLICANT(PRINT) TEL NO. LDMA Perm# •( Z
0`_.as owner of the property, or my employees with wages as Z
their sole compensation, will do the work and the structure is ADDRESS O0{'="7 s
not intended or offered for sale (Section 7044, Business and FINAL DATE At Q 'tr
Professions Code.) �J :�,CI.f� =1
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL -Z �� J J o.2
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
El I, as owner of the property, am exclusively contracting with Q
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY f Lf g,_
licensed contractors to construct the project (Section 7044, ves❑ No❑
Business and Professions Code.) e €I_TAL 67= 20
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING - -
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH I
COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR ( r;_�.
CONSTRUCTION LENDING AGENCY GUIDELINES. I'-#
I hereby affirm that there is a construction lending agency for YES❑ No❑ CHANGE ,1 lI I
N the performance Of the Work for Which this permit Is issued(Sec. I 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,
n 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. 01I_I!01'I0,l G
I J it
( o Lender's Address OWNER OR AGENT �Z C�i h
o :�_o
� o I certify that I have read this application and state under penalty P.C.
0 of perjury that the above information is correct.I agree to comply . EE PERMIT FEE
a with all county ordinances and State laws relating to building G/
CO const, ' n, and h by authorize representatives of this County ISSUANCE FEE
to er O abo I-mentioned property for inspectio urposes p!(p• 'T
sj� INVESTIGATION FEE TOTAL FEE / n
o [® V
Sgne e
SEE REVERSE FOR EXPLANATORY LANGUAGE