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HomeMy Public PortalAbout9508 LOWER AZUSA RD_Building__ APPLICATION � FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUIL DREss z as BUI ING�DRESS Q I hereby affirm that I have a certificate of consent to self insure, V or a certificate of Workers'Compensation Insurance,or a certified OI ZI copy thereof S c.380,Lab.C.) �a-p��r LOCALITY _ Policy No. ✓� G Company S/ dfi/ r _rU SIZE OF LOT NO.OF BLDGS.N ON LOT rtified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified Copy is filed with t county bujWng Inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. p� // Date C�Applicant ASSESSOR MAP BOOK PAGE PARCEL , • SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS © �� �,�,t,,g/� DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) /I I certify that in the performance of the work for which this permit CI .--, ( Z'9 I / 7 M ,'Q_ v Is issued, I shall not employ any person in any manner so as to ARCHITE OR ENGINEER TEL.NO.V of become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. `0nDWELL UNITS NOTICE TO APPLICANT: If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CQTRAXCTOR p'��� TEL . SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith IIT �Q� comply with such provisions or this permit shall be deemed revoked. ADD LIC.No. PL LICENSED CONTRACTORS DECLARATION CITY 4�G� L p LIC.CICS plL E o I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZr,17 NO.OF STORES NO.OF FAMILIES m Professions Code,and my license is in full force and effect. I NEW ❑ BK PG CD, License Number 3 1 7 7 Lic.Class CA I DgWRIPTION OF WORK 01 /� ADD ❑ VAL412ON W �17 CL Contractor AVA�E2trd' L'yJ_ R' Data 7-3,e!`:7,2 T1 ALTER [I ®� y ❑ I am exempt under Sec. REPAIR L /'� B.BP.C.for this reason �N/ 6 /`Y DEMOL ❑ LDMA P/C# Date' USE OF EXISTING BLDG. LIRM ❑ Signature APPLICANT(PRINT) TEL NO. LOMA Perm# ❑ I, as owner of the party, or my employees with wages as O their sole compensation,will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and FINAL DATE Professions Code.) WILLTHEAPPLICANTOR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL L ❑ I, 8S owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN �f Y 9 THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDER FINAL BY licensed contractors to construct the project (Section 7044, YES 11NO 11 `_` Vi1_ �r o Business and Professions Code.) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING '''• +'7-- OCCUPANTREQUIREAPERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH '•:i-1�L•fa di•_'o'tl CONSTRUCTION LENDING AGENCY FOR GUIDIEL QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST I hereby affirm that there is a construction lending agency for YES❑ NO❑ Jmmko— the performance Of the Work for which this permit Is Issued(See. 1 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES • COUNTY CODE.TITLEZ CHAPTER 220SECTIONS 2.20.100THROUGH 2.20.140 CONCERNING Lenders Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. Lenders Address 0 OMER OR AGENT 0 1 certify that I have read this application and state that the above information is correct. I agree to comply With all County P.C.FEE PERMIT FEE A. ordinances and State laws relating to building construction,and e[ hereby authorize representatives of this County to enter upon ISSUANCE FEE / the ab mentionedparty for' spection purposes. INVESTIGATION FEE TOTAL FEE JJ ' / n 1 / lilpmfmo of t 0e9 SEE REVERSE FOR EXPLANATORY LANGUAGE