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HomeMy Public PortalAbout9634 LONGDEN AVE_Building__ APPFICATION FOR BUILDING PERMIT CANTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION � FOR APPLICANT TO FILL IN BUILDI G DDRESS BUILDIN 7 .'� I hereby affirm that I have a certificate of consent to self insure, �y 04k/ or a certificate of Workers' Compensation Insurance,or a certified CITY v ZIP copy thereof(Sec.3800,Lab.C.) / F LOCALITY Policy No. Company SIZE OF LO NO.OF BLDG&NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS e/ CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER T L COMPENSATION INSURANCE p ! WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADD/ "V A f � DISTRICT GROUP T CONST. FIRE BANE PROCESSED BY dollars($100)or less.) G V C ZIPeEZ I certify that in the performance of the work for which this permit �W007 "or is issued, I shall not employ any person in any manner so as to A CHITS R ENGINE TEL NO. become subject to the Workers'Compensation Laws. STATISTICAL CL�AJSSIFICATION APT CONDO Date Applicant ADDRESS 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' CONTRACTOR— 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 SIDE CITY LIC.CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and _ NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. �,J NEW BK PG poll- d License Number Lic.Class D IPTI OF WORK ADD ❑ VALUATION Q Contractor Date ALTER ❑ $ �' O U 0 El am exempt under Sec. REPAIR 11 $ B.BP.C.for this reason DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. URM ❑ I CL CD Ignature APPLICANT(PRINT) TEL NO. LDMA Perm# F� r••^ y. z Z r•P:-'_I a s I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is ADDRESS - :y I? 121.135 not intended or offered for sale (Section 7044, Business and FINAL DATE Q - ! HEM = Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE r J tom' ❑ I, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY i I-IT(�l wL2 1 o =0 licensed contractors to construct the project (Section 7044, YES❑ NO❑ 1 I; its Business and Professions Code.) WILL THE INTENDED USE OF THE BUDUNG BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH -.0 SA t G if itscc al..: CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKUST FOR t i C. GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ NO❑ CM the performance of the work for which this permit is issued(Sec. m I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING �Ir[''t a 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, I L=`= TITLE 2,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 SCAOMD. 7:LIS i *1 4 c 5 6 ❑ Lender's Address OxvER OR AGENT 0 oI certify that I have read this application and state under penalty of perjury that the above informati correct.I agree to comply P.C.FEE PERMIT FEE N *a", ordinance an tat laws relating to buildingd he ze r sentatives of thi County ISSUANCE FEEco a t o p�Y for ins io rposes. CID INVESTIGATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT �( insure,or a certificate of Workers'Compenstion Insurance,or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY' Policy No. Company BUILDING ` Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS - /j�� 7-�• / �� �7�f ❑ Certified copy is filed with the county building inspec- BUILDING / 1 / / tion department. ADDRESSG 4oQ v Til_/ LOCALITYNEAREST _� .}��—•,//�� r// ���JJ Date Applicant CITY ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT �� •3O NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP �J hundred dollars ($100)or less.) TRACT$14/V 1� BLOCK LOT NO. NO. �v CG' TEL. PECIAL > I certify that in the performance of the work for which this OWNER NO. CONDITIONS O permit is issued, I shall not employ any person5/iff&7 r I, D RIOT GROUP TYPE FIRE P. SED BY ADDRESS ONST -15 so as to become subject to the War at . /y T ` @C Dat A Applica ru / CITY ZIP ©d ,; STATISTICAdI CLASSIFICATION APT. CONDO. f j NO ICE TO APPLICANT: If, after m Ing this certificate of T ARCHITECT OR TEL. . LU Exemption, you should become lect to the Workers' ENGINEER NO. CLASS NO. DWELL. UNITS 1 N Compensation provisions of the or Code, you must forth- ADDRESS SEWER MAP with comply with such provisi ns or this permit shall be, TEL e deemed revoked. CONTRACTOR V� NO. BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. i I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. ��qq Professions Code, and my license is in full force and effect. CITY CLASS V 00o, Q SQ. FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE $ Contractor Date DESCRIPTION OF WORK NEW ❑ ❑ 1 am exempt from the licensing requirements as I am a GZAAAG E' ADD licensed architect or a registered professional engineer ALTER t FINAL acting in my professional capacity (Section 7051, REPAIR DATE Business and Professions Code). USE OF DEMOL FINAL EXISTING BLDG. (� `❑ By c f Lic.or Reg.No. Date APPLICANT Q pAO NO. OWNER-BUILDER DECLARATION PRINT) C I hereby affirm that I am exempt from the Contractor's License ADDRESS 7 ©LL �� '� Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section kADDRE (� ❑ 7044, Business and Professions Code). TEL. `ll+ I, as owner of the property, am exclusively contracting CTOR NO. with licensed contractors to construct the project (Sec- y on 7044, Business and Professions Code). 1 ED TOTAL SETBACK FROM EXIST. 0 0 0 0 0 CONSTRUCTION LENDING AGENCY CK YARD HWY PROP. LINE WIDTH �j,hereby affirm that there is a construction lending agency for o a j C,0 q1 a performance of the work for which this hermit is issued 15ec. 3097, Civ. C.). 2.Lender's NameLender's Address $ Permit Fee y I certify that I have read this application and state that the Issuance Fee ' r above information is correct. I agree to comply with all County Investigation Fee 9 J ordinances and State Wr ing construction, Total Fej;" and hereby au,horize s County to enter f upo a-m fiection urposes. ga SEE REVERSE FOR EXPLANATORY LANGUAGE nature of AppliDote