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HomeMy Public PortalAbout5941 MUSCATEL AVE_Building__ - APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES Avis BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN qBU!ILDING�ADDRESSI hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS or a certificate of Workers'Compensation Insurance,or a certified copy there Sec.3800,Lab.C.) cT (� CITY ZIP Policy No. J °1'��/� Company J I mo" +' C ` o D c) LOCALITY - SIZE OF LOT NO.OF BLDG&NOW ON LOT , ❑ Certified copy is hereby furnished. 7 rC�)C-,�p oR/e NEAREST CROSS . ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. ` �`�� USE ZONE MAP NO. e ar ASSES P MAP BOOK PAGE PARCEL DatApplican L' V �• >I- ` �j � Q/ G SPECIAL CONDITIONS e CERTIFICATE OF EXEMPTION FROM WORKERS' OWN TEL NO. COMPENSATION INSURANCE Q l B WITHIN 1000 FT.OF SCHOOL? YES No (This section need not be completed if the permit is for one hundred ADDRESS dollars($100)or less.) 3 DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY YI certify that in the performance of the work for which this permit �� CIT " /y/©O 7 f,r/ �� 3 � is issued, I shall not employ any person in any manner so as toARCHITECT OR TEL NO. � ,nJ ZIP 7 become subject to the Workers'Compensation Laws. �1 pr eVl S Bre Usl�.• G�(� STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS^ CLASS NO. al DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate of / ;L `A -�� �CC_• C�rT REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR p TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith 4AUR Q / C/y7 OS�SK FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS ,,� LIC NO.O..� too(/r` PL 7-+ 41 /�3 L a"eTC� '/y 7 SIDE LICENSED CONTRACTORS DECLARATION CITY �n ^ f-,4— ^^ LIC.cIASs P L R�,G`T 4 I hereby affirm that I am licensed underprovisions of Chapter 9 I� SEWER MAP nnnn���� �y (commencing wit Section 7000)of Division 3 of the Business and SO./,U�Tl{SIZE NO.OF STORIES NO.OF FAMILIES ITErS 1T. o Professions Cod , ,gy i e�1 is in full force a .e^�f�ect. �V 7. �_ NEW BK PG y,IG(j" ��t �l o�4Y a License Numbe�r�� "/�' Lic.CI - / ESCRIPTION OF WORK ADD ❑ VALUATION O Contracto4-0 Ji,R —.rpt-T Date V S�O �c� �L ALTER ❑ `'��� HJT CH,�iiti�IE oQOV d $ ❑ I am exempt under Sec. REPAIR ❑ O(� �y �y •I �y B.BP.C.for this reason 0 DEMOL 11LDMA P/C# (MOO—Ml 815/7., Date: USE OF EXISTING BLDG. URM ❑ a- Signature APPL6NT LVI) /� � TEL NO. LDMA Perm# JL 1 AH 10:409 2.❑ I, as owner of the property, or my employees with wages as V`r�C� t��(7 OCA Z A : as their sole compensation, will do the work and the structure is ADDRES _ ,,/F O not intended or offered for sale (Section 7044, Business and j % 'a— '4 11 QL FINAL DATE a 3303 2269.56 Professions Code.) I WILL THE APPLICANT ORF RE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL (` 1 ITEMS OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ I, as owner of the property, am exclusively contracting 4 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GU!DE? FINAL BY licensed contractors to construct the project (Section 7044, TOTAL 2269.56 Business and Professions Code.) YES❑ NO❑ CJ WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK 2269.56 \`� OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH �-C CONSTRUCTION LENDING AGENCY ;2ET ' COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR CHANGE n fk�i GUIDELINES. 4�11"INGE 00 I hereby affirm that there is a construction lending agency for YES❑ NO❑ cl the performance Of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ,^� �y 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, �{�QO�-0001 11/ 9/95 TITLE ,CHAPTER 2 20 SECTIONS 2.20 100 THROUGH 2.20 140 CONCERNING HAZARDOUS Lender's Name MATE RE NG AND F OBT ING A PERMIT FROM THE SCAOMD. 3238 q AM 90 12 o Len s Address OO 1 ER RTA Z- 0 I certi that I have read #his a lication and state under penalty 9 of a ury that the above nfor tion is correct.I agree to comply P.C. /,p 7r�/ PERMIT FEE h / N wi h II county ordin 's a State laws relating to building d�jp c ns r tion, and her b utt) iI representative$g of this County ISSUANCE FEE O ro t e u nth bovr� property for i s►bec pyl bo pG�� ro �>'ti INVESTIGATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE