HomeMy Public PortalAbout5827 MUSCATEL AVE_Building__ APPLICATION FOIE UILDING PERMIT
• COUNTY OF LOS AELEBUILDING AND SAFETY.
WORKER'S COMPENSATION DECLARATION I FOR APPLICANT TO FILL IN BUILD G ADCSS
ITU DING AD RES
I hereby affirm that I have a certificate of consent to self insure, G
or a certificate.of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) CIT�LCi/L `�_- i _�- ZIP � �� LOCALIT
Policy No. Company' SIZE'o�Lor G [`!`O.-OF BLDGS, OW ON LOT
❑ Certified copy is hereby furnished. ;, NEAREST CROSS ST.
❑ Certified opy's filed with the county.building inspection
(TRACT BLOCK LOT NO. r
departm nt. USE ZONE MAP NO.
Date Plica ESSOR MAP PAGE r PARCEL
/ C/ / SPECIAL CONDITIONS
10
CERT( KATE OF EXEMPT( FRO W RK RS•' ' ER TEL NO.
WITHIN 1000 FT,OF SCHOOL? YES ' NO
COMPENSATION INSURANCE 6 _
) ' ADDRE S,
(This section need not be completed if the permit is for one hundred � `� /p #� DISTRICT GROUP ` TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.)
I certify that in the performance.of•the work for which this.permit
is issued, I shall ndt employ any person in any manner'so as to CITY
ARCHITECT OR'ENGINEER TEL NO.
become,subject to;the Workers'Compensation Laws. r—
y.• STATISTICAL CLASSIF�ATION APT CONDO
Date Applicant DDRESS ..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'4• CONTRACTORTEL NO. SET BACK YAR�DHWY PROP LINE WIDTH
Compensation provisions-of the Labdr,Code, you must forthwith FRONT
comply with such provisions or this per shall be deemed revoked.�QADDRESS LIC.NO. P L I
r LICENSED CONTRACTORS DECLARATION `� SIDE
`- CITY LIC.CLASS
PL SI',: °•=t.'
I hereby affirm that•I am licensed underprovisions of-Chapter 9 }
(commencing with-Section 7000)df Division 3-of the Business and S SI NO.OF RIES NO.OF AMILIES SEWER MAP 'g T
_ a
Professions Code and license is in full force an fest. NEW BK/� PG �d. Q
TOTAL 1136.*,-- C
L•, DESCRIPT NOF WOK VALUATION F ;
License Numb Lic.'Class ADD ❑ .at3o �y,77On1
ContAIRZI �6��. %� ALTER ❑ �. "1O OO tz
El i-111 C
❑,I am exempt under,Sec. ... ..... . ...... ..
REPAIR $ -CHANGE'.� -
B.&P.C.for this reason DEMOL ❑ W
USE OF EXISTING BLDG. LDMA P/C#
Date: URM ❑ ' H Q i1/ 3/0_:,�
`.`Signature APPLICANT PRINT . TEL,
( )' TEL'.N0. LDMA,Perm#
❑ I,'as owner of the property, or my employees*-with wages as z
their sole compensation;willdoJhe-workand the structure is ADDRESS 0d 1 jT tj`V•
not intended or offered for sale.(Section 7044, Business'and'w. FINA12 DATE Q r .. .r:
P ssions Code.) ; I1 f.AI
,-.,/(pie WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL _•5 _
I(�I 83 owner. of the property, am'exclusively-contracting,with OR A MIXTURE CONTAINING A HAZARDOUS•MATERIAL EQUAL TO OR GREATER THAN THE I `� -"I.-
YES
` Q E'i +: ••r{E,t
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINA I By "
licensed contractors to construct the,project (Section 7044, vas❑ No❑ 5
Business and-Professions Code.) �{( rr
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING :��
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH %r' .• `'• •' '
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES
hereby affirm that there is a construction lending agency for YES 13NO 11I "' -.�f } "330001-0 101
a the performance•of the work for which this permit is issued(Sec. s ':36657
' .
o) I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ' i 1 �'`� °nI!
N 3097,CIV.C.) CHECKLIST.I U DERSTAND MY REQUIRE E D THE LOS ANGE S COUNTY CODE, ' ' I'` °�'D
Lehder's Name MATE 2, R 2.20 SECTIONRS 2. I MIT 2 R .r THCON HAZARDOUS '
aLender's Address
CI ONNFeR OR A6EM
cI certify that•1 have read this application and state under penalty
e of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
N with all county ordinances and State laws relating to building \
construction, and hereby authorize representatives of this ounty ISSUANCE FEE
m' to ante on the above- wort for in ction� s
INVESTIGATION FEE TOTAL F
m � a
r` 64nahw a app v roam
SEE REVERSE FOR EXPLANATORY LANGUAGE