HomeMy Public PortalAbout4901 FIESTA AVE_Building__ '
APPUCAMORFOR BULUNG PERMIT
COUNTY OF LOS ANGELS 4 BUILDING AND SAFETY
WOR7CER'S COMPENSATION DECLARATION *,_FOR"APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS '•���� G(/11A.
or a certificate of Workers' Compensation Insurance, or a certified 01 1 IF=5 a
copy thereof (Sec.3800,Lab.C.) CITY ,+ ZIP �O
Policy No. Company L LOCALITY L
SIZE OF LOT ' NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. X NEAREST CROSS 9T.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SL�q 020 �Z SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. ��
COMPENSATION INSURANCE ` 2-Rv WITHIN 1000 FT.OF SCHOOL? YES No
(This section need not be completed if the permit is for one hundred v� ADDRESS
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 NA CITY ZIP
117
is issued, I shall not employ any person in any manner so as to ARCHITECT O ENGINEER TEL NO. vQ '
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADIDRIESS CLASS NO. �L DWELL UNITS
T. ti
NOTICE TO APPLICANT If, after making this Certificate Of (J
REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CON ACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwithu9A?!0!UN V 3-
FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESSS�a,� LIC.N p L
LICENSED CONTRACTORS DECLARATION 5250 �� M�7N r! SIDE
CITY LIC.CLASS PL
I hereby affirm that I am licensed underprovisions of Chapter 9 L►0 S SEWER MAP
(commencing with Section 7000)of Division 3 of ttie Business and so T�SI7�p� NO.OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full forc4and ect. �+1 NEW ❑ BK PG �-
License Numbe( Lic.Cl8SS D C IP ON OF WORK ADD VALUATION
Contractor _ Date ALTER ❑
'4
31-94 cc
❑ I am exempt under Sec. REPAIR ❑ $ 0
U
B.&P.C.for this reason £� Q DEMOL ❑ 1 LDMA P/C# UJ
Da 2v® USE OF,0!71EXISTING BLDG. URM 11i CL
Signature !6� \V APP (CANT(PRINT • TEL NO. ' ' �'LDMA Perm# :23 Z
❑ I, as owner of the-property, or my employees with wages as Z (;f": °
07
their sole compensation, will do the work and the structure is ADDRESS _o
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 3 —r I
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE JJ7
El 1, as Owner Of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL B y,I
licensed contractors to construct the project (Section 7044, YES❑ NO❑ TTS {
Business and Professions Code.) =i— -`
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING -y-p4 ¢''�
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH n� (' TOTAL j AL 7.87� � P,�§8 �
CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR. Q�'®L.+ �J
GUIDELINES.
I hereby affirm that there is a construction lending agency for No❑
CHECK
ves❑
N the performance of the work for which this permit is issued(Sec. /C
r. r
rn I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING CHANGE
N 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS
3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
a
o Lender's Address
d OWNER OR AGENT
r. ...
o I certify that I have read this application and state under penalty � i:
o P.C.FEE PERMIT FEE 249 3 AM 1 y
of perjury that the above information is correct.I agree to comply POPr �� �+.
N with all county ordinances and State laws relating to building d
m construction, and hereby authorize representatives of this County ISSUANCE FEE
ato enter upon the above-mentioned property for inspection purposes. p�p�461 1
INVESTIGATION FEE TOTAL FEE 14
signature of Aaoiicam o.Agem Dale
SEE REVERSE FOR EXPLANATORY LANGUAGE