HomeMy Public PortalAbout4700 H MILLER DR_Building__ } - APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
•
WORKER'S COMPENSATION DECLARATION
FOR APPLICANT TO FILL IN PBUILDINGDRESS
I hereby affirm that I have a certificate of consent to self insure, Ror a ce�rt✓iiffiicat(((eS$$e of Workers'Compensation Insurance,or a certifiedCIV ,V`.38Uo, I ZIP L�
cy o Company SI E OF LOT NO.OF BLDGS.NOW ON LOT J
❑ Certified copy is hereby furnished. `�/ NEAREST CROSS ST
rtified copy is filed with the county building Inspection TRACT BLOCK LOT NO. USEZONE MAP NO.
\\ depa 7nt'.fj�/' J 'E PARCEL T�
Date,CC �G7l PPllcant �iC-� n ASSESSORpAAP 9K t3 0 PARCEL � /
/ gcLJ-- � /17
SPECIALCONDITIONS `LA�
CERTIFICATE OF EXEMPTION FROM WORKERS' �+Iv + T No Z! WITHIN 1000 FT OF SOHO YES N 9
COMPENSATION INSURANCE ADD
(This section need not be completed if the permit is for one hundred DISTRICT GRTYPE CONST.' FIRE ZONE P CESSED Y
dollars($100)or less.) C1 _V
ITY zIP V 1
I certify that in the performance of the work for which this permit �'V vl A / v x 5 �� ' 'a
Is Issued, I shall not employ any person in any manner so as to ARCHITECTOR ENGINEER TEL NO
become subject to the Workers'Compensation Laws. Z STATISTICAL C /91 F'
APT CONDO
J Date Applicant A CLASS NO. DWELL UNITS
NOTICE TO APPLICANT: If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become Subject t0 the WorkersCTCIR TEL.Na. 7,el-
SETBACK 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. A DREssr IC.NO. P L `
213SIDE
LICENSED CONTRACTORS DECLARATION �r PITY IC•�s P L (' T P v
I hereby affirm that I am licensed under provisions of Chapter g 7� SEWER MAP ��.
SQ.FT E NO.OF STORES NO.OF FAMILIES
(commencing with Section 7000)of Division 3 of the Business and �+�)�7 487i0•
Professions Code,and m license Is II force and NEW BK PG , 1 TTEMS
License Number. ic.Class C ION F WORK t ADD ❑ VALUATION V W
Contractor LdL'r? Date — G1.URM
ALTER ❑ TOTAL x 81'7" 0::K
REPAIR ❑ $ /' d D 8 . ao CHECKOar n�l:l
❑ I am exempt under Sec. Q CHANGE
� � j
BARC.for this reason DEMOL ❑ 1
USE F EXISTING BLDG. LDMA P/C#
Date: 11� �. ❑ fin tO/I
Signature \ APPLICANT(PRINT) L LDMA Perm# [
0001-0001 18/90
�❑ 1,as owner of the property, or my employees with wages as 0 O 1331 1 AM i0 o 2
their sole compensation,will do the work and the structure is R
not intended or offered for sale (Section 7044, Business and Z.C� FINAL DATE]"�{/ //p� C
Professions Code.) WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL '( 1 ( `I J U
❑ 1, as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN
THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project (Section 7044, YES❑ NO❑
Business and Professions Code.) I
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING � I/
OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH Q,
CONSTRUCTION LENDING AGENCY COAST AIR DUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST (L/_
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. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD "^( r.J 7' Y^'• to-1 -} p y i
3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LQS A.KQELES
OOUNTYCODE•TITLEZCHAPTER2.20SEGnONS21D.100THROUGH2.2Ml4QQONe.ESNTNG y� X� �� r i {^•j C^F
Lenders Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING APERMIT FROM.. E AnMD. �, )'1.1
IL
r..1i Lrs
a Lenders Address Drwlma+nDo+r °-�� 'rj �•' I` t•-1 ".)H �ih
o• I certify t I have read this application and state that the above
infor ti n Is Ct. I agree t0 Comply with all county P.0 FEE PERMIT FEE > D 1 p1 I,
0rdi as to law Iating to building construction,and (Q d a J
he au orize p arty
for
of this County o enter po ,y /.�+y_ ISSUANCE FEE /�
men ned a for Ins Ion purposes. "�.
INVESTIGATION FEE TOTAL FEE 1' `I 1- 1
` -•.I
8gnauoo oiNNe a �m _J
SEE REVERSE FOR EXPLANATORY LANGUAGE
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