HomeMy Public PortalAbout6112 IVAR AVE_Building__ COUNTY OF LOS ANGELES � BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDIN '9DDRESS
WORKER'S COMPENSATION DECLARATION
BUILDING ADDRESS oZ v
I hereby affirm'that 1 have a certificate of consent to self insure, V111or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) CITY ZIP 4 LOCALITY
Policy No. Company SIZE O T NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. O. X / G NEAREST CROSS ST.
Cl Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE' MAP NOZ5,01
'� 2 /
ASSESSOR MAP BOOK PAGE PARCEL �� r`7l
Date Applicant 0 Q 2 d / / SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS'. OWNER ' TEL.NO. ! YES NO
COMPENSATION INSURANCE 7 WITHIN 1000 FT.OF SCHOOL?
ADDRESS
(This section need not be completed if the permit is for one hundred -7111 S DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
dollars($100)or less.) CITY, zip / p d
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. _a__1L DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become Subject t0 the Workers' CONTRACTORO TEL.NO. SET BACK YARD HWY• PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith FRONT
comply with such provisions or this permit shall be deemed'revoked. ADDRESS �, LIC.NO. PL
LICENSED CONTRACTORS DECLARATION CITY uc.CLASS p L SIDE OC-
I hereby affirm that I am licensed under'provisions of Chapter 9 ❑ SEWER MAP CS
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF
STORES NO.OF FAMILIES O
Professions Code,and my license is in full force and effect. ' . NEW BK PG.
DESCRIPTION v
I N OF WORK ADD' VALUATION D W
License Number Lia Class ,�•E of Q2 — p-O ti
o�oJ OZTD
Contractor-" Date �,�V7 � � ALTER C3Z
❑ I am exempt under Sec. REPAIR El
B.BP.C.for this reason DEMOL ❑ LDMA P/C#
USE OF EXISTING BLDG.
Date'. URM. [:]
Signature APPLICANT(PRINT) TEL.NO. LDMA Perm# tib. . ,.
Vyl, as owner of the property, or my employees with wages as O
their sole compensation,will do the work and the structure is ADDRESS F, - _ -1
not intended or offered for sale (Section 7044, Business and FINAL DATE
7 _J
Professions Code.) i i'`I
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL j
❑ I, as owner of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN I I i�'J a
Y g THE AMOUNTS SPEC ED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL B �.
licensed contractors to construct the projectt.(Section 7044, YES❑ NO'� _: :raw.;
Business and Professions Code.)
� WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING � "OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTIONOR MODIFICATION FROMTHESOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST
I FOR GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ NO❑
the performance of the work for which this permit is issued(Sec. -O j;ji,-ja C i 1 y ,L =t
3097,CIV.C. . ( I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD
PERMITTING CHECKLIST.1 UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES
�. COUNTY CODE,TITLE CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.100 CONCERNING 0.8= =
a Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. '
Lender's Address ~ 4- —NM ORAGENT
o 1 certify that I have read this application and state that the above RC.FEE PERMIT FEE
information is correct. I agree to comply with all county oZ6. 3
ordinances and State laws relating-to building construction,and
a. hereby authorize representatives of thist unty t rater upon ISSUANCE FEE
the above-mentioned property for i pection pur ses. 3 `—
a . a %O_2—qA INVESTIQAfl&FEE TOTAL FEE ,{ q
sp,un,n,a Applkanl w Aoem DM - �y
SEE REVERSE FOR EXPLANATORY LANGUAGE.