HomeMy Public PortalAbout10508 FREER ST_Building__ APPLICATIONFOR- BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING ADDRESS
WORKER'S COMPENSATION DECLARATION 1 ,
I hereby affirm that I have a certificate of consent to self.Insure,• BUILDINGADDREF2S 11 !�
or a certdicate,of Workers' Compensation Insurance,or_a•certified D15
C`Q') �C 1 �
copy thereof(Sec.3800,Lab C) �K _ (J�T Y ZIPQ"I`S ^
` v LOCALITY
Policy No. Company SIZE OF LOT 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' OWNS n e')1 TEL NO S
COMPENSATION INSURANCE 6b R N tt W , WITHIN 1000 FT OF SCHOOLS 1 .
YES NO
(This section need not be completed If the permit Is for one hundred ADDRESS
DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
dollars($100) or less)
CITY ZIP
I certify that In the performance of the work,for which this permit g/n
Is Issued, I shall not employ any, person In any mann-r so as to Zil
become subject'to the Workers' Omp sation Laws. ARCHITECT OR ENGINEER TEL NO
STATISTICAL CLASSIFICATION APT CONDO
Date:?,—.- O ��Appllcant ADDRESS CLASS NO �/ DWELL UNITS
NOTICE TO APPLICANT If, after making this` Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should becomesubject to. the Workers' NT.CTOR t T/ NO �� SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith b��f QJG FRONT
comply with such provisions or this permit shall be deemed revoked ADDRESS ,n LIC0 PL
LICENSED CONTRACTORS DECLARATION s 9 RJB() 64-1`? 2 SIDE
CIT = l/ LIlf. P L
I•hereby affirm that I am licensed underprovislons of Chapter 9 i 'SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SQ FT SIZE NO OF STORIES NO OF FAMILIES
Professions Code,an y license I In full force and ffect NEW C1 BK- , PG pop.
CL
License Number Llc Class DESCRIPTION OF WORK ADD, E] VALUATION O
Contractor 0 SJR. Date S-AO,g 3 �� 1$�g ALTER. .❑ $ o? 6-D �� 0
❑ I am exempt under Sec ? vw `," ;REPAIR, l ; 0
B&P.0 for this'reason DEMOL`'❑ LDMA P/C# III0
Date • USE OF EXISTING B DG- URM ❑ IL
Z
Signature
APPLICANT(PRINT) TEL NO - . LDMA Perm# 1 .• - Z
8
❑ I, as.
owner of the property, or.-my employees with wages as Z ,ACIC tT=s
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 A C 1i11� {xI 1iI.,'I�
Professions Code) WILL THE APPLICANT OR FUTURE-BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 3� Z i J 1 1TEI IIS
E3 I, as owner Of the property, am exclusively contracting withOR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE?. FINAL BY
licensed contractors to construct •the project (Section 7044, I i 1 i�� 1 17 - 90,
Business and Professions Code) yes I No El. r
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK 117 a 91 I
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _
-CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR �^'n j� -.iii ;E .j I J
GUIDELINES JYryP �'tl'7 LI
I hereby affirm that there Is a construction lending agency for YES❑ NO❑
a the performance of the viork for which this permit Is Issued(Sec.
a, 3097,CIV C) ]HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING
CHECKLIST,I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,, - 0 0 '7
TITLE 2,CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS ' `0001—V f 1 3/10/93
3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD _
• i1
o• Lender's Address OWNER OR AGENT L��;1 . f AM ��
0
o I certify that I have read this application and state under penalty
0 of perjury that the above information is correct. I agree to comply PC FE PERMIT FEE
cN .with all county ordinances and State laws relating to building 9a-ate
W con truction, and hereby authorize representatives of this County SSUANCE FEE
co
to er up he above-me tioned property for inspection purposes •
< _ INVESTIGATION FEE TOTAL FEE*
m
s w of�oi�i o,A��, Gale
SEE REVERSE FOR EXPLANATORY LANGUAGE
01
.76A636A'CE'b803 2-6 P.LI`CATiON�FOR�`BU ILDI �G.. 'PERMIT -
' `COUNTY`OF.I.OS'<ANGELES EIIJ I NG
DEPARTMENT OF COUNTY ENGINEER ' ,ADDREss
' BUILDING AND SIAFETY='DIVISION L;',
,ti •LOCAL'ITY, i
JOHN A. LA481 E; Cou NT- ENGINEER. NEAREST= `t
'-"f-''W_ILLIAM A. JENSEN,'SUP'r of Bu_ILDING �.�J� -i1` CROSS ST
• ,i - •,- _ - � ' DISTRICT NO•' �.GROU .{, TYP - I PR=S ?Y
FOR APPLICANT"TO,":FILL -IN. ,�O coNST.,,.
BUILDING A.
- - ^STATISTICALCL 'SSIFICATON?, .SEWER`MAP -
ADDRESS,'/''4 y S;'v'D, •8, •.. i..v. 'f`, .B�_ FG ,
CLAS$ NO '' DW.E LL'UNITS ^, _
�'LOT;NO: .BLOCK, r ,WATER
CERTI FICATE.•;+NOT REQUIRED- RECEIV.ED� - "•'
TRfKCTt;';:,�. •� �; -,--'• _MAP', HIGHWAY
�'' "' , .',,-• -
k". NO..OF BLDGS; NO 4 ".�., STATE MAJOR SECOND OCAL
".,(CIRCLE)
? $IZE;OF LOT�� " �''• + -N O,W ON LOT,—'' -,""'SPECIAL USE ZONE �. -
;USE'OF: • ".:, a?'�+ "2- - - • (CONDITIONS
•EXISTI NG BLDG'
TE
, 1 "'L,
•'�' ,•.OWNER,' ,+ ,+ ' NO"." BUILDING, EXIST. '
{�Y•.4RD_-'HWY• :`STREET NAME
_ SETBACK WIDTH
ADDRESS.,'}^�J, GLi+Os FRONT; �/'^'� _ 'QQ Q '
`ARCHITECT OR TEL P'. L 'V.' -'�� L� -
- :Ef�{GINEE•R-,'a:�1".'- .t �, NO -` - - ',$IDE
CO NTR_ACT,OR' A^; N Q(� ,vgyp 'aanp ;r
'ADPRESSc '� ELb _ '� .. .c•. ,,.•.,.�,�: �r• �f F—
_ DESCRIPTION OF WORK; _ w
• Z
NEW •ADD- - ALTERS REPAIR• _�-i'DEMOLISH '• - ,
SQ 'FT: - . �NO••,OF NO OF• .: - - - r` Pi, - 'I. ,
"SIZE' {/ - '$TOR FAMILIES
USE'OF ' '
',STRUCTURE•
SIGNATUREnOFU1/.. i I •t„ `• •� - •' -
.VALUATION'$+ ' `,'.ya ,.L-v`J�f V:10
,•.t, _ I• o'`. - -- - •4••. ..
-APPROVALS '• J,DATE �10 `]N'PECTOR'S SIGNATURE
P C _ ''pwj T. r'{; FOUNDATION',"LOCATION
��'' - �•I,' ,-P�''•
FEE,
•p��•v- FORMS-MATERIALS
17b� •-' 4 .. -
c.. 'FRAME:'FIRE STOPS, JJ` 1,\ -
I H� EB. _ACKNOWL.EDGE THAT I 'HAVE REA D•THIS,'APPLICATION :_BRACING; BOLT$!'---. `' v „i/ .\ -
•�"AND STATE.THAT.jHE.A5OyE IS;CORRECT.AND AGREE,TO COMPLY. FURNACE- LOCATION_
WITH 'ALL COUNTY- ORD,INANCES-'AND'kSTATE LAWS-REGULATING GAS VENT, DUCT$
BUILDING CONSTRUCTION '-I!CERTIFY THAT IN DOING THE•WORK
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY'PERSON IN_V'IOLA-. L'ATH. INT �' ' .�(• / _(.'
'TION OF'THE LABOR'CODE'OF THE STATE;'OF CALIFORNIA"RELAT:-
ING TO WORKMEN�S C MPENSATION,INSURANCE _ LATH. EXT ' ",�,• - � r
HOUSE'NUMBER•COR-, '`'•
` SIGNATURE'OF,7` + �
PERMITTEE-•' `•RECT AND POSTED 'I _ '�•i `- I•
'"ADDRESS. , �` - ,FINAL �/��4.3'' .• •.�' .
"' ''• y" '" .JOHN F.-LEWIS', PRINCIPAL STRUCTURAL ENGINEER:'• '
PLAN-CHECK'-VALIDATION.,: '.'CK MO'-_ CASH :,' _•: PERMIT VALIDATION CK M O.
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