HomeMy Public PortalAbout5930 MUSCATEL AVE_Building__ . - APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRES ^�7— /
I hereby affirm that I have a certificate of consent to self insure, BUILDING AD C1
ESS II,, n SL�`7 1 ,
or a certificate of Workers'Compensation Insurance,or a certified s4l"O V X,�*�
copy thereof-(Sel' l/ 0, ab.C.) ���� CITY ZIP I,
-t '1 L LOCALITY
Policy No. Company SIZE OF LOT NO.OF BLDG&NOW ON LOT
El Certified copy is hereby furnished. NEAREST CROSS ST.
,Iu Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
ep`rt e t.
Date ` V,p1 l/� P� Ute' USE ZONE MAP NO.
dd Applicant ` V "" '`� ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL
COMPENSATION INSURANCE
S WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need be completed if the permit is for one hundred ADDRES �^ C
V DISTRICT GROUP TYP CONST. FIRE ZONE PROCESSED BY
dollars($100)or le .)
CITY---t,. ZIP
I certify that in the p formance of the work for which this permit
is issued, I shall not a ploy any person in any manner so as to
become subject to the (kers'Compensation LAWS. ARCHITECT OR ENGINEER TEL NO.
STATISTICAL CLASSIFICATION APT CONDO
Date Applic t ADDRESS CLASS NO. '� - DWELL UNITS
NOTICE TO APPLICANT.• I after making this Certificate of REQUIRED' TOTAL SETBACK FROM EXIST
Exemption, you Should be ome subject t0 the Workers' C gCTQR/1 TEL NQ �O SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith gs'
FRONT
comply with such provisions or this permit shall be deemed revoked. pppgEgB LIQ PL
LICENSED CONTRACTORS DECLARATION I SIDE
CRYQA N r l� LIC.C C SS PL
I hereby affirm that I am licensed underprovislons of Chapter 9
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF$TORIES NO.OF FAMILIES SEWER MAP a
Professions Code,and mayfliicenBe is in full force and a fect. ll NEW ❑ BK PG �
210 L C- DESCRIPTION OF WORK VALUA
License N•—uym.�b�er� Lic.Class _ ADD ❑ j � O
Contract; "' 0 Date Cj � a ALTER ❑ � 43
/rT v
� w
❑ 1 am exempt under Sec. REPAIR $ z
BAP.C.for this reason W m $ DEMOL ❑ —
. LDMA P/C#
MURM Date: USE OF E TING BLD ❑
Signature APPLI �lT�(�,� pn— T�EO. LDMA Perm#
1.) ❑ 1•as owner of the property, or my employees with wages as UV '"—`•may ^ �a_ei6 a Z /'•'•v
their sole compensation, will do the work and the structure is ADDRESS O
not intended or offered for sale (Section 7044, Businessand FINAL DATE a
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL T L
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE �r M t�E 3F
❑ I, as owner of the property, am exclusively contracting 44, AMOUNTS SPECIFIED O E-HAZARDOUS MATERIALS INFORMATION GUIDE? 0. Q 3.
licensed Contractors to construct the project (Section 7044, YES❑ FINAL BY > , `AI 105 a 30
Business and Professions Code.)
CITAL
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING - �• •t i i•C�,°���s
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH j IECUK 2
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES "HANG
.!•�(��G
1_• t'1FYti !!q
I hereby affirm that there is a construction lending agency for YES❑ No
CY the performance Of the WOfk for which this permit IS ISSUed(Sec. 1 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
13097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMEN DER THE LOS ANGELES COUNTY CODE.
cm TITLE 2.CHAPTER 2 20 SECTIONS 2.20.100 JIRROUGH 2 20.140 CONCERNING HAZARDOUS
z Lender's Name MATERIALS REP0RTING,?0 %0BTAININ A PERMIT FROM THE SCAOMD.
o Lender's Address L�'•T6 1_ A I IG R_S I
CI OWNER OR AGENT '
o I certify that I have read this application and state under penalty
O of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE O
$ with all county ordinances and State laws relating to building
construction, and hereby authorize representatives of this County ISSUANCE FEE
to entqupoon the abopm�enfloon�ed property for inspect! pur gses. �s cv•�)LO
n ' Y •L/_<(. 7 p-1 / INVESTIGATION FEE TOTAL FEE !I
StMum a ent APO=[a Ag !/J (/
SEE REVERSE FOR EXPLANATORY LANGUAGE