HomeMy Public PortalAbout6211 MUSCATEL AVE_Building__ . • . - APPLICATION FOR 13UII:I®1iVG PERMIT
COUNTY Of LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
BUILDI G ADDRESS yw
I hereby affirm that I have a certificate of consent to self insure, % V ��s e!i
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sc.3800 b.C.) CITv 0 G r'/3-
ZIP ! 7,��
/ �' � LOCALITY f
Policy Not Compan SIZE OF Lar NO OF BLDGS NOW ON LOT
❑ Certified copy is hereby furnished. S t 1Vd;07&0E NEAREST CROSS S
❑ Certified copy is filed with the county building inspection TRACT Q BLOCK LOT NO.
depart nt ++y�,am,.� J7 n� D✓ USE ZONE MAP NO.
Date 4 y Applicant '�O /SCJ(//i ASSESSO MAP OK PA�o PPRP/ SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER G L NO.
COMPENSATION INSURANCE Cdt! D ��'l-� S` s l � WITHIN 1000 FT OF SCHOOLS ves No
(This section need not be completed if the permit is for one hundred ADDRESS _
p r DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
dollars($100)or less.) � Iv ' � �7v'
CITE ZIP
I certify that in the performance of the work for which this permit
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is issued, I shall not employ any person in any manner so as to 11� ARCHITECT R ENGINEER TEL NO.
become subject to the Workers Compensation Laws. \R STATISTICAL CLA IFI ATION y / APT CONDO
Date Applicant �y ADDRESS CLASS NO. � DWELL UNITS
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NOTICE,TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SE�AGK LROM ],EXIST
EXemptick you should become subject to the Workers' C/o�nIrR�ACTO �p TE N SET BACK YARD HWY P L•I E s H
Compensation provisions of the Labor Code, you must forthwith A L �f � / �� FRONT 3303 5':-4_�
comply with such provisions or this permit shall be deemed revoked. A S u PL }
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LICENSED CONTRACTORS DECLARATION CITY ^ LIC.CLASS SIDE T:T�! _= C.�
I hereby affirm that I am licensed underprovisions of Chapter 9 L�fT 7SEWER MAP
(commencing with Section 7000)of Division 3 of the Business an SQ T SIZE NO.OF STORIES NO F FAMILIES 1 2053.401
r�°4 Q'
[:, ,053
Professions Code,and m license is in full force and ffect. l7 NEW BK PG � C
DESCRIPTION OF WORK VALUATION , CHANGE °!t)C:
License Numbe Lic.Class ADD ❑ �,Q CHANGE LL
Contractor Date �� �� ��� ALTER ❑ $ ` •7
❑ I am exempt under Sec. REPAIR ❑ $ 1/12/96 Z
B.&P.C.for this reason DEMOL ❑ LDMA P/C 4246 1 A 9°7)Irl
Date: USE OF EXISTING BLDG. URM 11
Signature APPLICANT(PRINT) TEL NO. LDMA Perm C 1
❑ I, as owner of the property, or my employees with wages as ADDRESS ZO ACC I °v
their sole compensation, will do the work and the structure is
not intended or offered for sale (Section 7044, Business and FINAL DATE /y J a �,j[�,? 2479.67
Professions Code.) WILL THE APPLICANT OR FUTURE BUIUSNG OCCUPANT HANDLE A HAZARDOUS MATERIAL
❑ I, as owner of theOR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE {
property, am exclusively contracting with44. AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUiDE9 FINAL BY _ IT M r
licensed contractors to construct the protect (Section 7044, YES 11 No❑ U � TOTAL I y�- 2�'79°67
Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BU:UXNG CHECK 2 7
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH f °ry�'
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT BCAOMD)SEE PERMITTING CHECKLIST FOR CHANGE
.00
GUIDELINES HA
I hereby affirm that there is a construction lending agency for YES 1:1NO❑
the performance of the work for which this permit Is Issued(Sec. I 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, �/ �'}r��'
TITLE 2,CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS 0000-0001 v
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERVIT FROM THE SCAOM.D.
Lender's Address f til; 1
OWNER OR AGENT
3 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 PC FEE PERMIT FEE
with all county ordinances and State laws relating to building r✓C`�r� �� Ot T��'
m construction, and hereb authorize representatives of this County ISSUANCE FEE
to a
enterc the che� Toned property for inspe51jo urpose
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INVESTIGATION FEE TOTAL FEE
tv 19..Ms 6 a Appo A "� D:.
SEE REVERSE FOR EXPLANATORY LANGUAGE