HomeMy Public PortalAbout9230 FLAHERTY ST_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING DDRE S /
I hereby affirm that I have a certificate of consent to self insure, BUILDIN DDRESS
or a certificate of Workers' Compensation Insurance,or a certified Q
copy thereof(Sec.3800,Lab. C.) CIT ZIP
Policy No. Company 1Q ' 9-0 LOCALITY
SIZE OF OT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CROSS ST.
❑ 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
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' WNER TEL NO.
COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDRESS
DISTRICT GROUP TYP CONST. FIRE ZONE PROCESSED BY
dollars($100) or less.) AM h4
CIT t ZIP
I certify that in the performance of the work for which this permit �n� _�
is issued, I shall not employ any person in any manner so as. t0 ARCHITEC OR ENGIN ER TEL NO. (jle
become sUbjeCt t0 the Workers'CCommppelnr`ation Laws. n STATISTICAL CLASSIFICATION APT CONDO
Date Applicant �IJC��, �F� ADDRESS - CLASS NO. � DWELL UNITS
NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRA T R TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith 1
� FRONT
comply with such provisions or this permit shall be deemed revoked. D S NO PL
LICENSED CONTRACTORS DECLARATION ^ SIDE
al&l L C. SS 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 ISlZ NO.OF STORIES I NO.OF FAMI S _
Professions Code,and my license is in full force and e ect. NEW El BK PG , }
CIDDESCRIPTI OF WORK VALUATION O
License Number Lic.Class r� ,_ � � � � ADD ❑ U
Contractor S Date /0-¢6-93 ALTER ❑ $
cc
El
ElI am exempt under Sec. REPAIR ❑ $ Q
BAP.C.for this reason DEMOL ❑ LDMA P/C# W
Date: USE O EXISTING BLDG. - URM ❑ CL
Signature APPLICANT(PRINT) TEL NO. LDMA Perm# '''I S'" Z
❑ I, as owner of thero ert or m employees with wages as Z
p p y y em p y O g ADDRESS
their sole compensation, will do the work and the structure is _ _ .•„_
not intended or offered for sale (Section 7044, Business and FINAL DATE a t lt=j�_ 1.05 - 30
Professions Code.) ` .. _, 11-15- i1
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ( —I/ J 5_�1,_i.ks,
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE °_�_
❑ I, as owner Of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? Q
licensed contractors to construct the project (Section 7044, FINAL BY > i a, - F�{
YES❑ NO❑ i+Hl1='
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR r = r
GUIDELINES. I�(•—%I��'i�
I hereby affirm that there is a construction lending agency for YES 11No Eltis i-,1-the performance of the work for which this permit is issued(Sec. �L i ii t ii'° -
r::
m 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, "'"''...""."'-.."""..
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.
0 Lender's Address
0 OWNER OR AGENT
o I certify that I have read this application and state under penalty
0of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
o with all county ordinances and State laws relating to building
OD
construction, and hereby authorize representatives of this County ISSUANCE FEEco
to er upon th Qbo m tinned property for inspection purposes. Q
a - l/e
INVESTIGATION FEE TOTAL FEE
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SEE REVERSE FOR EXPLANATORY LANGUAGE