HomeMy Public PortalAbout6418 LIVIA AVE_Building__ i
r � ""UCATATION, FOR BULLING PERNT
COUNTY IL OF LOS ANGELES'' y BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING A DRESS
I hereby affirm that I have a certificate of consent to self Insure, BUILDING ADDRESS e.r, Y
or a certificate of Workers' Compensation Insurance,or a certrfied (P 2A0 L-4 If,A A Y e
copy thereof(Sec 3800,Lab C) CITE_ ,--f- cy ZIP t 7 LOCALrrY
Policy No Company SIZE OF LOT NO OF BLDGS NOW ON LOT
❑ C tified Copy IS hereby furnished - NEAREST CROSS ST
Certified copy is filed with the county budding Inspection TRACT - BLOCK LOT NO •
department I A USE ZONE MAP NO '
Date C' -121-9-5 Applicant v✓TM'� � . i ASSESSOR MAP BOOK.. PAGE Q`B PARCEL -
wt-0 5/_77�� ODS SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' �Q OWNER TE NO YES N /
COMPENSATION INSURANCE `f` ` 4 l$3'"�`L Y?l-L-47, �ij, S-7 may WITHIN 1000 FT OF SCHOOL
(This section need not be completed If the permit IS for one hundred ADDrRE�Sn h
dollars($100)Or less) ' tv T/zo �r1A Avc DISTRICT GROUP TYPE CONST' FIRE ZONE PROCESSED BY
I certify that in the performance of the work for which this,perm
CITY
C;(1-f
is Issued, I shall not employ any person In any manner so as to ARCHITECT OR ENGINEER TEL NO - O�
become subject to the Workers'Compensation Laws ,. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS /Vll,a C a
CLASS NO DWELL UNITS
NOTICE TO APPLICANT If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CgNTRACTOR�e �J TE NQ,•,I��^ SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions-of the Labor Code, you must forthwith ✓\J4,44,AS !/T/' /.44, g 6 FRONT
comply with such provisions or this permit shall be deemed revoked ADDRE,9'A� Aad /!O�� LIG��� 7 SIDE
s
LICENSED CONTRACTORS DECLARATION CITY J-/ �S - W LIC CLASSY PL
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and124.
F IZE NO OF STORIES .NO OF FAMILIES
Professions Code,and my IlIccense s In full force and effect NEW 1:1 ( PG a
License Number - f Llc Class D SCRIPTI N O RK - - - - ADD VALUATION - > - Q
Contractor Date ��- S —A00T,:,, 1 Off`Y /-ate ALTER ❑ U
(La*tm,�p�l-• Xi rE,4 6A77-► ,
ElI am exempt under Sec w^�'''Y REPAIR ❑ �� Za0 .a0 e�
►
B&PC for this reason J ON �?�/5�.�(, DEMOL ❑ -,'�� U
Date tO��L-yS USE OF EXISTING BLDG - URM ❑
Signature - APPLICANT(PRINT) TEL NO LDMA Perm# -t„ ,{t,, ' � °L ¢Z
❑ I, as owner of the property, or my employees with wages as
Z
their,sole compensation, will do the work and the structure Is ADDRESS 0
,not Intended or offered for sale (Section 7044, Business and FINAL 'i� "E t
Professions Code) WILL THE APPUCANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
El1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED'ON THE HAZARDOUS MATERIALS INFORMATION GUIDESQ
FINAL Y �� �••'u,
licensed contractors to construct the project (Section 7044, 14 •,i_I q 1 -t:€ I j} ;;_:;r-,`1
VES❑ NO❑ '
Business and Professions Code)
_ WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING , r , {IL;•j, y ,I'{i a!t. j
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES
I hereby affirm that there Is a construction lending agency for VES❑ No❑ - /•'�9>j V r - .i'.' '
N the performance of the work for which this permit Is Issued(Sec 1" -
- IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING
3097,CIV C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, r• IT1
TITLE 2,CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS v m } r d In
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD
Lender's Address
0 OWNER OR AGENT , ••
0 1 certify that I have read this application and state under penalty �$
0 of perjury that the above Information Is correct I agree to comply PC FEE L� PER IT F 'p '
$ with all county ordinances and State laws relating to budding / / /�
m struction, and hereby authorize representatives of this County p ISSU Z• Cr
m to e r upon a%�=r Inspection purposes �� Z i -9 kil
< G' INVESTIGATION FEE TOTAL FEE
(=I I«Ag- DWa
SEE REVERSE FOR EXPLANATORY LANGUAGE n ri iI