HomeMy Public PortalAbout6203 HART AVE_Building__ ADPL C AMON FOR. BUD UNG pER�][i T .
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL<IN, Bul 1N ADDR 8'""
I hereby affirm that I have a certificate of consent'to self insure, ME
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or a certificate of Workers' Compensation Insurance,or a certified
copy.thereof(S c.3800,Lab.C.) ,.r��� �J /'► ZIP LOCALITY -
P��olic//yN+o. Company J "�'/ NO;OF BLDGS.NOW ON LOT
e--Certified copy is hereby furnished. NEAREST CROSS 8T.
❑ Certified copy is filed with the my buildin pection ,TRACT BLOCK LOT NO.
dep rtment. USE ZONE. MAP NO.
` "Date / - AppliCant ASSESSOR MAP BOOK 'PAGE PARCEL- -
2 SPECIAL CONDITIONS
RTIFICATE OF EXEMPT FROM WORKERS' WNER L` ✓ YEEESS, NO'
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OMPENSATIO INSURANCE pYJ Cs WITHIN 1000 FT.OF SCHOOL?
- not be cRE�$SSSS ._ ..
(This section need Completed if the permit is for one hundred �j�� �y G/r DISTRICT GROUP TY CONST. FIRE ZONE PROCESSED BY
dollars'($100)or less.) V Yvll �iCC�.
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(.certify that in the performance of the work for which this permit 17 7-0
is issued, I shall.not employ any person in any manner so as to 4—
ARCHITECT OR ENGINEER TEL NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date - Applicant ADDRESS - - .CLASSNO. �`�— 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 /' C T �cp.I�O ,,J�' - SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you,must forthwith Web '/I✓Z� : ✓��'�^' FRONT'
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC,NO, P L
LICENSED CONTRACTORS DECLARATION _ ?yq-� s� ��� LI .C '7 PILE
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and 5Z.FT,-GV, NO.OF STORIES NO.OF FAMILIES .
Professions Code,and m license is in full force and effec�,
License Number Lic.Cla—
p(dI CL
NEW BK PG D }
RIPTION OF ORK ADD VALUUATITION7 Q
,�tenn / 1:1 $✓� 7 U
Contractor /�S/ Date' ALTER El_
REPAIR iff O
❑ I am exempt under Sec. $ H'
BAP.C.for this reason /J2 DEMOL El LDMA P/C
Da US F EXISTING BLDG. URM ❑5z^ 1 _ - .q CL
Signatur� / APPLICANT(PRINT) TEL NO. LDMA Perm# ir•-. r z
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❑ I, as'owner of t roperty,or my employees with wages"as »_
their.sole compensation, will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DATE Q in> »_
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ` l'�' � •�j 1 •�• -'
❑ I, as Owner of theproperty, am exclusive) contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE y
Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY � �+s
licensed contractors to construct the project (Section 7044, ° I�''' I- '` '-
- YES❑ NO❑ r - r..r. •
Business and Professions Code.)
• WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING , _.4:`. •�•�•-°'-'�'
_ OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR �1 �)
CONSTRUCTION LENDING AGENCY GUIDEUNES. HAI( ':IC
1113
I hereby affirm that there is a construction lending agency for YES❑ No❑
w the performance of the work for Which this permit Is Issued(Sec. 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, I`}_i I If'I ' r� L
TITLE 2.CHAPTER 2.20 SECTIONS 2,20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS "- 'i" '
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. a
o Lender's,.Addressfi I'%
OWNER OR AGENT
O
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
CO constru and hereby thorize represe tatives of this County ISSUANCE FEE jA
to n up the above- ned prope for inspection purposes. (p v
a INVESTIGATION FEE TOTAL FEE
r` sgaawre o1 AOWeani a A i Dare
SEE REVERSE FOR EXPLANATORY LANGUAGE
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