HomeMy Public PortalAbout4915 MCCLINTOCK AVE_Building__ APPLICATION FOR R ILDING PERMIT
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COUNTY OF LOS ANGELES r. BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION / FOR APPLICANT-TO FILL IN, BU I I DDRESS
BUILDING ADD I F
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I hereby affirm that I have a certificate of consent to self insure, .
or a certificate Worke ''fCo tion Insurance,or a if' d `` t or1�4��CA
copy th@1 .-Ob Lpje ZIP r_ LOCALITY
.Policy Nb. 1 l Company '` [ SIZE OF L ( /7 NO.OF BLDGS.NOW ON LOT 1
❑ Certified copy is hereby furtINRANCE
NEATEST CROSS ST
idle opy is filed with inspection TRACT BLOCK LOT No.
de a m USE ZONE MAP NO.
ASSESSOR MAP BOOK PAGE PARCEL
Date Applicant { SPECIAL CONDITIONS
C FICATE OF EXEWORKERS' N ��— /�'1�" �� / T �� YES No
COMPENSA6 WITHIN 1000 FT.OF SCHOOL?
(This'section need not be completed if the permit is for one hundred A SS
V�, DISTRICT GROUP E CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.)
CITY ZIP
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 ENGINEERL NO.
TE
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO.. Ca I DWELL UNITS
N077CE TO APPLICANT. If, after making this Certificate Of REQUIRED' TOTAL SETBACK FROM EXIST
Exemption, you 'should become subject to the Workers' CO � Y.
SET BACK YARD HWY PROP LINE WIDTH
R
Compensation provisions of the Labor Code, you must forthwith ( Z'-/'. Q � Z / FRONT
comply with such provisions or this permit shall be deemed revoked. A Sg S4 ��/ L(0.N� �� PL
LICENSED CONTRACTORS DECLARATION l 0 g� SIDE
c r eh Qi UC;.CLASS�+ 3 PL
I hereby affirm that I am licensed underprovisions of Chapter 9 Q a
(commencing with Section 7000)of Division 3 of the Business andSIZ� NO. RIES NO.OF FAM141ES SEWER MAP
Professions Code n I ens is in full foroe a e p/� [/ NEW ❑ BK PG v
License Number' Lir.Class :! S ION OF WO ADD ❑ VALUATION polo.' 0
Contractor Date ALTER ❑ $ � v
W
om
n.
❑ 1 am exempt nd r Sec. REPAIR ❑ $ Z
B.BP.C.for this reason s ��j �J DEMOL ❑
LDMA P/C# �.
Date: USE OF ERfffiNG BL URM ❑
Signature AP NT I J r ?„ T LDMA Perm# �1(_1 i
❑.I,;as owner of•the property, or my employees with wages as Ap• G J Z -r;j =y
their sole-compensation, will do the work and the structure is 7 ,/ ti O "`�''� 16
not intended or offered for sale (Section 7044, Business and l v �+*T' FINAL DATE a 0-3303
ti
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL t �� a - ;- ii''('.•r'�s
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE i 1 i 111_-
' ❑ 1, as owner of the property, am exclusively contracting 44, AMOUNTS SPECIFI N THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY > _
licensed contractors to construct the project (Section 7044, OTA'
�
Business and Professions Code.) j
VES No
WILL THE INTEN O USE'OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDINGL,L
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ® HECK �G�a a}5
CONSTRUCTION LENDING AGENCY, COAST AIR DUALITY MANAGEMENT DISTRICT(SCAOMO)SEE PERMITTING CHECKLIST FOR
GUIDELINES CHECK
I hereby affirm that there is a construction lending agency for YES 11N ''
a the performance of the work for which this permit is issued(Sec. L," yr CHANGE W I HAVE READ T, MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING I / 1 IvTiH4 43` °L•!!
3097,Civ.C.) CHECKLIST.I UN E,ATE
REQUIREM UNDER THE LOS ANGELES COUNTY CODE, '
TITLE 2,CHAPTER SE IONS 0 THROUGH 2.20.140 CONCERNING HAZARDOUS
Lender's Name MATERIALS REP A 'F AWING A PERMIT FROM THE SCAOMD.
C3 Lender's Address
c OWNER OR AGENT ^VL �
c I certify that I have read this application and state under penalty46z 6 i ) Vii-( 9-0251
of perjury that the above information is correct.I agree to comply .P.C.FEE PERMIT FEE �-
N with"all county
ordi c and State laws relating to building
construction,and h uthodze representatives of this County IfISUANCE FEE /
m to enter upon th - entioned.property for in tign'purFses.� Cp 7
[y'
INVESTIGATION FEE TOTAL FEE
m Cs�
SEE REVERSE FOR EXPLANATORY LANGUAGE