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HomeMy Public PortalAbout8919 HERMOSA DR_Building__ APPLICATION FOR BYILD. ING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANTJO FILL IN BUIUDINGIA5E�,ESS I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation InSUrance,or a certified copy thereof(Sec. 3800, Lab.C.) LOCALITY Policy No. Company NO.OIF BILDGSX ON LOT tj,-�We- Z�� 13 Certified copy is hereby furnished, SIZE NEAREST GROSS ST. or 13 Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. I I USE ZONE MAP NO, Date Applicant ASSESSOV RAG E PARCEL 41f/9- J?-)L0 SPECIAL CONDITIONS � YE CERTIFICATE OF EXEMPTION FRO Wo ERS' /L,N M eZ4 .2 �IITIIN 1000 FT.OF SCHOOL? YES NO COMPENSATION INSURAINCE RK ASRt2l 'it I (This section need not be completed it the perm, is for one hundred DISTRICT GROUP TYPECONST. FIREZONE PROCLSSEDBY dollars($100)or less.) CITY I certify that in the performance of the Work for which this perrnit,�N is issued, I shall not employ any person in any NY AW ZIP ff become subject to the Workers'Compensation L-..-. A HIFFECT OV ENU hu I STATISTICAL CLASSIFICATION Date_ Applicant APT CONDO NOTICE TO APPLICANT. If, after making this Certificate of Ii DWELL UNITS _ "ir /-"I W-� " ?/, /-REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR r TEL NO. —SET BACK YARD HWY PROELLINE WIDTH Compensation provisions of the Labor Code, you must forthwith lee�� FRONT A-. -T � comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO, P L LICENSED CONTRACTORS DECLARATION SIDE CITY LIC.CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing With Section 7000)of DiI 3 of the Business and NO,OF STORIES NO,OF FAMILIES Professions Code,and my license is in full force and effect. N S;� NEW a( BK PIS 599 - 3�� License Number Lic.Class DESCRIPTION OF ADD C] VALUATION $ /S 0-10 Pi DR Contractor Date E3 r:,I HA REPAIR 0 I am exempt under Sec. $ DEMOL 0 BAIRC. for this reason LOMA P/C# Date: TJ St �MING URM 0 -1 Fj'-)-L VA, -1�i . 1 "M L I"r-W Sign8luro APPLII(MINT) fill" LOMA Pem r.1 rL.-,Z 1, as owner of the property, or my employees with wages as z 0 their sole compensation, will do the work and the structure isl 16 5,� not intended or offered for sale (Section 7044, Business and INAL DATE IT, Professions Code.) WILL THI APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL INS as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE AMOUNTS SMWFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE' FINAL BY it[ > HL 1 1F. ,-7---rc�fged contractors to construct the project (Section 7044, *­ffusiness and Professions Code.) YES N .11 TRIP RE N IN D USE OF THE BUIDIFING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT DO E A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH V GUIDEUNES / ANAGEMENT DISTRICT(SCACMD)SEE PERMITTING CHECKUST FOR f:HPH1JE .00 CONSTRUCTION LENDING AGENCY COAST AIR DUALITY M EA I hereby affirm that there is a construction lending agency for YESO Ntq 2- the performance of the work for which this permit is issued(Sao �--- -r- / Y/ 3097,Civ.C.) I HAVE READ THE HAZARDOUS MATERIALS INFORMANONGUCE AND THE SCAOMO PERMITTING CHEC LIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNT'Y CODE 7 IT­E�' 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 1� P-1 Lender's Address 0 DA CH.�T I certify that I have read this application and state under penalty FEE ERMIT FJ% of perjury that the above information is correct.I agree to comply �7,FA -7 7 0 with all county ordinances and State laws relating to building construction, and hereby authorize representatives of this County ISSUANCE FEE76 IF nsfgectmn�rpi REP :2 t te th a t ad property fc 4kls n r fV :!,,upon a a ovP-men o INVES IGATION FEE QIJJW5=� TOTAL 14awwr SEE REVERSE-ECIRE P ANATORY LANGUAGE TT" 0 V �m � 1 4-IC/ -q APPLICATION FOR BUILDING PERMIT n I-\ COUNTY OF LOS ANGELES, BUILDING AND SAFETY FOR APPLICANT TO FILL IN. !"Di „A ' v -rte' ' WORKER'S COMPENSATION DECLARATION �i [�/,�' j/lY ' BUI �A RE T`��VV hereby affirm that have a certificate of consent to self insure, 4/ �� IS* or a certificate of Workers'Compensation.Insurance, or a certified I Copy thereof (Sec. 3800, Lab. C.) CITY . ZIPS♦ r (�}� Policy No. Company ZEF OT �.O NO.OF DGS.NOW ON LOT •G BVV El Certified copy is hereby furnished. X /o" NEAREST CROSS ST ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. t5-0 X12' Late Applicant ASSESSOR tJB,SgL$ PAG)=n PAORCEL_ ©iJ lNll 0 /- (/ SPECIAL CONDITIONS CERTIFICCOMPENSATONINSURA CE ORKERS' owNER '� pI'np,lp f.�e rEL _N� C,vY(/ Nl t. WITHIN 1000 FT.OF SCHOOL? VES' NO (This section need not be completed if the permit is for one hundred ADD ES �, - DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars ($100) or less.) . I certify that in the performance of the work for which this permit ZIP Q O m I y_✓i,+ is issued, I shall not employ any person i0 any manner so as t0 ARCHITECT R E INEE O �J become subject to the Workers'Compensation Laws, STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS 1'�/� �,�T .r �� CLASS NO. DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate Of Gt •r � 6vVj'V REOU I RED TOTAL SETBACK FROM EXIST Ji Exemption, you Should become subject to the Workers' CO TR CT R - TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith I. FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS' LIC.NO. P L LICENSED CONTRACTORS DECLARATIONCITY LIC.CLASS P L SIDE 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.SIZE NO.OF STORIES NO.OF FAMILIES NEW ❑ BK PG J��7 a Professions Code,and my license is in full force and effect. License Number Lic.Class ESCRIPTION WORK I M ADD ❑ VALDA Q EI Data 1- ALTER $ 0 ❑ I am exempt under Sec. Y (y}� REPAIR ❑ $ F- B.SP.C.for this reason DE MOL )�, LDMA P/C u W Date: Us F E IsnN DG. URM ❑ i Signature APP G (PR��IN11T 1 O CDMA Perm R Z ❑ I,'as owner of the property, or my employees with wages BE NmkN t " • TtI4ZO - their sole compensation, will do the work and the structure is A S - not intended Or offered for sale (Section 7044, Business and FINAL DATE Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL O f'- 8 ORA NTSSPMIXTURE SPECIFIED ON THE A HAZARDOUS MATERIAL INFORMATION r0 OR GREATER THAN THE J I'•t�',_I .S ❑.I, en owner Of the property, am the project contracting mg Wlth AMOUNTS SPECIFIED ON THE HAZAROCUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the protect (Section 7044, YES>( NO Business and Professions Code.) - __ _ w1LL THE INTENDED USE MI THE DUELINGCONSTRUCTION BY THE APPLICANT OR NNRE BUILDING ' y 5 OCCUPANT R QUALITY A PERMIT FOR CONSTRUCTION OR EE PERMITTING FROM THE SOUTH FOR I [ il CONSTRUCTION LENDING AGENCY Go AIR MANAGEMENT DISTRICT(SCAOMDI SEE PERMITTING CHECKLIST FOR ��++�����c p �qq�� 7 -,-, y�- �N' :5"K I— 1A(�••T ;I- i til— I hereby affirm that there is a construction lending agency for YE..KT No❑ ` v the performance of the work for which this permit is issued(Sec. '"( r:NE;;i3 :_310 Oc p. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 3097, Civ.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, W TITLE 2,CHAPTER 220 SECTIONS 220.IDO,THROUGH 2.20.140 CONCERNING HAZARDOUS L,rZnI�UIG e Lenders Name MATERIALS REPORTING AND FOR OBTAINING AYERMIT FROM THE SCAQMD. o Lender's Address ` o - I certify that I have read this application and state under penalty of perjury that the above information is correct.I agree to comply PCF MIT FEE �•'"` with all county ordinances and State laws relating to building Al -l` P + .5�. a...�. ;;_.n_ yE 1i'1' nconstruction, and hereby authorize representatives Of this County - I ISSUANCE FEE + o D enter upon the above-mentionetl property for insp Vj11(J„rj1^/Aur sf 11 2 INVESTIGATION FEE TOTAL FEE I < D��re � 8 •GS SEE REVERSE FOR EXPLANATORY LANGUAGE ,