HomeMy Public PortalAbout10420 MILOANN ST_Building__ ry �. APPLICATION UPERMIT
ION FOR BUILDING
� L
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self insure, O� '/ 14 1 � G'
or a certificate of Workers'Compensation Insurance,or a certified CITY G�u ZIP `
copy thereof c.3800,Lab.C.)
LOCALITY
Policy No. Company-�d SIZ P.f T NO.OF Bf S.NOW ON LOT L
❑ 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.
depa men yn
Date Applicant ���C,��Z i'1 G .1421 (Q ASSESSOR MAP BOOK PAGE PARCEL
a SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER n , TEL NO.
COMPENSATION INSURANCE 6 WITHIN 1000 FT.OF SCHOOL? YES No
(This section need not be completed if the permit is for one hundred ADDRESS
L Z N DISTRICT GROUP TSE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.)
CITY ZIP Ic— C-141
I certify that in the performance of the work for which this permitT 2� 4 ,� ( , 6 O ,.
is issued, I shall not employ any person in any manner so as to ARCHITECTOR ENGINEER TEL NO. _ ` =�LLG�GsGa/
P�
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE 70 APPLICANT.. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR n f TEL NO. , SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith `�i;y. g��4++� o tiY 3 V FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS s t7 � p L
LICENSED CONTRACTORS DECLARATION " J �� SIDE
CITY LIC.CLAS P L
I hereby affirm that I am licensed underprovisions of Chapter 9 Vl.t �v r�� -1`71 7e �� SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SO.FT.9ZE NO.OF oRIES I No.OF FAMIUES
Professions Code, nd m lic ns is in full force annq eff ) NEW ❑ BK PG d
License Number i LIC.Class �� GI DESCRIPTION /WORK ADD ❑ VALUATION 1 O
Contractor r W "�► Date h7or, ;- ACCT s 4
[ e `� ALTER 11 '3�6 ' L C.1
Ce- .- C /►
❑ I am exempt under Sec. / ( �-1{_ REPAIR 1:1 $ 3303 142,20
BAP.C.for this reason ` `O,�til Q1 ; T; �•v DEMOL ❑ 1 ITENS W
LDMA P/C#
Date: USE OF E STING BLDG. URM ❑ TOTAL JL '` �'�D
Signature APPLICANT(PRINT) TEL N y rC/ LDMA Perm# .cam
❑ I, 9a owner of the property, or my employees with wages as 1/ti1 0'd C — / // Z CHECK 142.20
their sole compensation, will do the work and the structure is AD ESS 4• 5- O CHANGE e00
not intended or offered for sale (Section 7044, Business and �i:1 k-� /kQ _ �' FINAL DATE�/ /� C
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
❑ I, as owner of the property, am exclusively contracting with AMouMNTS S ECIFIED ONRE ING THE HAZARDOUS MATERIALS NFORMATO GU GUIDA HAZARDOUS MATERIAL EQUAL TO OR E?
THAN THE FINAL BY r' > QuQ0—Vt�V 1 11/ 919
licensed contractors to construct the project (Section 7044, YES❑ NO❑
Business and Professions Code.) 3250 1 AN10=0$
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BULDIN6
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR
GUIDEUNES
I hereby affirm that there is a construction lending agency for YES❑ NO❑
a the performance of the work for which this permit is issued(Sec.
mI HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
CM 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
o Lender's Address
0 OFFER OR AGENT
o I certify that I have read this application and state under penalty
0 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
$ with all county ordinances and State laws relating to building
construction, and hereby�avt horize representatives of this County ISSUANCE FEE �� Q
m toe ter upon the abovioned p arty for inspec ion p
���y INVESTIGATION FEE TOTAL FEE G/
Samw a Avg a Awn
SEE REVERSE FOR EXPLANATORY LANGUAGE