HomeMy Public PortalAbout5936 HART AVE_Building__ . .
COUNTYOF LOS ANGELES BUILDING AND SAFETY
1>J
•V X.WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO ILL IN '. BUILDING ADDRESS`/
L
BUILDING'ADD
I hereby affirm that have a certificate of consent'to self insure, /
or a certificate of.Workers' Compensation Insurance,,'or a certified
copy thereof..(Sec.3800,Lab.C.) CIT f ZIP,
/� C �• ti:�' .� .,� ��.. `�° ��, )LOCALITY
Policy No. Compeay_`3�' -
- SIZE OF LO ANO OF BLDGS NOW ON LOT
[I �-7 Certified copy is hereby furnished, �j v j NEAREST CROSS ST. _
El Certified copy is filed with the county building,inspection TRACT BLOC LOT NO. L{ZV 0's'/�
departm nt. j' USE ZONE MAP NO.
ASSESSOR MAP BOOK_ PAGE PARCEL
Dat I Appli c
SPECIAL CONDITION'
OWNBR - NO
ER IFICATE OF EXEMPT N F/AN�C
OR ERS'
COMPENSATION INSUE /t/1 �� �a WITHIN 1000 FT.OF SCHOOL?
` ADDRESS -
(This Section need not be completed if the permit is for one..tiundred., / 7J!' / fC �w w /�' DISTRICT GROUP TYPE CONST. FIREi ZONE PROCESSED BY
dollars ($100)or less.) G e{ /fes V p
I certify that in the performance of the work for which this permit `
is issued,.) shall not employ any person in any manner so as
'to CITY _ > zIP
become subject.to the Workers'Compensation Laws. ARCHITECT OR E�NEER - TEL NO. •dam,
P, STATISTICAL CLA SIFI ATION APT TTP
CONDO
t,
Date Applicant ' ADDRESS - CLASS NO. � DWELL-UNITS
NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBln FROM Ex1ST
Exemption, you should become' subject to the Workers'' C05&A7CTOR 'f /" .� a` TE / SET BACK YARD .,.-HWY - PZ..PlINE WID7•j+
Compensation provisions, of the Labor Code, you must forthwith �� /1� C- -' FRONT "ta'''' `• J - -
comply with such provisions or''this permit shall be deemed revoked. ADD LIC.NO. F L - '• �`lf,t
LICENSED CONTRACTORS DECLARATION C.CL S � SIDE -
- _CITY LIC.CLASS PL : -• - � .
I hereby affirm that I am licensed underproylsionS.,of.Chapter 9 • S T. IZ.F NO.OF TORIES NO.OF .SEWER MAP - - - -
(commencing with Section 7000)of Division 3 of the Business ander �' FAMILIES NEW BK PG
' Professions Code,and�my license is-in full force and effect. � D
✓4 - ❑
VALUAOLicense Number LtLic.Class DESCRIPTION OF W RK ADD ❑ QU$Contraate r ��lALTER a
REPAIR ❑
❑ I am exempt under Sec. - - �-- $
PAP.C.for this reason .DEMOL 1:1LU
• _ LDMA P/C# W
Date: USE OF EXISTI LDG:' URM ❑ 0-
C/)
Signature -• - .APPL,PAN={PRIN ) v 7 LDMA Perm# -.r_ Z
❑ I as owner of the property, or.my employees with,wages as O orf_+,!na
their. sole compensation, will do the work and the structure is ADDRESS
not.intended Or Offered for sale (Section 7044, Business and f FINAL DATE 0 _I :� , 49.76.
_
Professions Code.)' °f+�.
- WILL THE APPLIGA RFUT E BUILDI OCCUP HANDLE A HAZARDOUS MATERIAL
0-e`
OR A MIXTURE AWING HAZARD S MATE L EQUAL TO OR GREATER THAN THE J
0-e as owner of the property, am.exclusively contracting .with AMOUNTS SPECTRE/.N THE HAZARD S'MATERIALS INFORMATION GUIDE? FINAL B � `� t -;'
licensed contractors to construct the project.(Section 7044; yE5❑ NO LS Aiii,
IJT
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 { i"Y 6 -+''
CONSTRUCTION LENDING..AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR J " ° ^`
-1
GUIDELINES. - .1CHANGE C!
I hereby affirm that there is a construction lending•agency for YES E3NO V / f r "
a the performance of the work for which this permit is issued(Sec.
p
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 HAZAR OUS •�",//�° 0000
' ('� -
Lender'S Name MATERIALS REP TING AND FOR OB NG A PE T THE SCAQMD. / VtJL' -iiJ •7 ljq/ Y{
p Lender's Address - avNea OR ncsAr ����, .. -. . 19{i:A 2 A i 10:1.,
o t
o I certify that I have read this application and state under penalty
o of perjury that the above information is correct.I agree to comply P.C.FEE. / PERMIT FEE - �
with all county ordinances and State laws relating to building O'
construction, and hereby authorize representatives of this County, .ISSUANCE FEE '
toenter n the above- ntio d perty for' ection pu
m 6 INVESTIGATION FEE TOTAL FEE /: / O
� sgnzwre a1 Mor�ao neem oe�e 7 !o
SEE REVERSE FOR EXPLANATORY LANGUAGE