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Home My Public Portal About8903 HERMOSA DR_Building__ APPLICATION FOR B1 .DING PERMIT COUNTY OF LOS ANGELES �r ;� BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILc` DRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) CITY ZIP -NO ` ` LOCALITY.. -, Policy N0. Company LG SIZE i OF LOT NO.OF.BLDGS.NOW ON LOT /`A Cl ❑ Certified copy is hereby furnished. /v NEAREST CROSS ST C1Certified copy is filed with the county building inspection THII BLOCK LOT NO. department. ' USE ZONE MAP NO. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWN R TEL NO. COMPENSATION INSURANCE JO �O! WITHIN 1000 FT of SCHOOL? ves No (This section need not be completed if the permit is for one hundred ADDRESS ��, DISTRICT GROUP TYPE CONST. FIRE ZONE �RDCESSEDdollars IS 100)or less.)I certify that in the performance of the work fr which this permit C Q - ZIPiS issued, I Shall rat employ any person 10 an manner so as to ITEG OR ENG EER TEL NO. become b' t t the Workers' p cation STATISTICAL CL�TION APT CONDO Date 9 Applicant A ADDRESS CLASS N0. DWELL UNITS NOTICE TO APPLICANT..- If, after making this Certificate of ' REQUIRED' TOTAL SETBACK FROM EXIST Exemption, you Should become subject t0 the Workers' CONTRACTORMJ'- ' TEL NO. SET BACK YAgD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith X-Z-R ✓ comply with Such provisions or this permit shall be deemFROM ed revoked. ADDRESS LIC.NO. F L LICENSED CONTRACTORS DECLARATIONSIDE CITY LIC,CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP > (commencing with Section 7000)of Division 3 of the Business and SO.FT Z NO,OF STORIES NO.OF FAMILIES d Professions Code,and my license is in full force and effect. - NEW ❑ SK PG License Number Lic.Class DESCRIPTION OF NARK VALUATI ADD ON xx) _ � Contractor Date D ALTER ❑ $ �`� C'u.� 60 w ❑ I am exempt under Sec. REPAIR ❑ $ Z B.BP.C. for this reason DEMOL ❑ LOMA P/C s Date: USE OF EXI L URM ❑ Signature APPLICANT(PRINT) TEL N0. LOMA Perm �I as owner of the property, or my employees with wages as Z t eir sole compensation, will do the work and the structure is ADDRESS O --1 _ not intended or offered for sale (Section 7044, Business and FINAL DATE �1t S Z _ Professions Code.) WrLL THE APPLICANT OR FUTURE BUILDING CLGUMNi HANDLE A HAZARDOUS MATERIAL J i- ❑ "OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE I, as owner Of the property, am exclusively contracting WIIM1 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY j licensed contractors to construct the project (Section 7044, YES NOXI bli .Business and Professions Code.) -I-(-i: 5 ! "T1 WILLTHEINTENDED USEOF THE BUIDUNG BY THE APRIGNT OR FUTURE BULgNG ✓ '-- - OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION oP MOgFlCATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUAUTr MANAGEMENT DISTRICT ISCAOMDI SEE PERMITTING CHECKUST FOR GUIDEUNESl� 1 hereby affirm that there is a construction lending agency for YES C3 No TO L =619 f °-'�+ N the performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING D -'r -' 3097,Civ.CJ o:H-E,I•;y,, w I CHECKLIST 2,CH UNDERSTAND TI NS 220EMEMB UNDER THE LOS ANGELES COUNTY COOS. - TITLE I CHAPTER ANG SECTIONS OBTAINING THROUGH FROM O CONCERNING HAZARDOUS Lender's Name 1-ARTERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMO N Lender's Address 41ir'sti_ - O ovmLR w+weNT b 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 P.C.FEE �j T� PERMIT FEE ry with all county ordinances and State laws relating to building 154 construction, construction, and hereby authorize representatives of this County IISSUANOE FEE �� j_<_�y I• he ab9 r-m 'o ed property cr ivnspecti n perp gs.k4l!&ro � INVESTIGATION FEE ' TOTAL FEE �' . SEE REVERSE FOR EXPLANATORY LANGUAGE