HomeMy Public PortalAbout6217 MUSCATEL AVE_Building__ 1 APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN�/� BUILDINGDRESS
I hereby affirm that I have a certificate of consent to self insure, BUIL NG ADDRESS
or a certificate of Workers'Compensation Insurance,or a certified 2
copy thereof Sec,..3/8�00,lLpb.C.) CIT ZIP
Policy No/ ��`� `v Compan uf ,y `-7T ���7� LOCALITY
SIZE OF LO NO.OF BLDGS.NOW ON LOT 77 a1 C
❑ Certified copy is hereby furnished. 3.6 X (� NEAREST CROSS S
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
depart nt. ,,e�J` 1�e�,, �1/ i, USE ZONE MAP NO.
Date Applicant /�l�i !�/Y/G� �T,Yf arrL. ASSE MAP K PAGE PARS/��
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER o. 7�4�,//
COMPENSATION INSURANCE G� -4-10 .� g.:-1-746 YES WITHIN 1000 FT.OF SCHOOL? Yes No
E ED EY
(This section need not be completed if the permit is for one hundred ADDRESS
�U !LYrF 77-9- DISTRICT GROUP TYPE CONST, FIRE ZONPROCESS
dollars($100)or less.)
I certify that in the performance of the work for which this permit CI ��� /e ��! ZIP917� �G G �Y
is issued, I shall not employ any person in any manner so as to [ O
become subject to the Workers'Compensation Laws. ARCHITECT R ENGINEER TEL NO.
STATISTICAL CLASSIFICATION APT CONDO
Date Applicant M ADDRESS CLASS NO. �Z DWELL UNITS f/
N077CE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you Should become subject t0 the Workers' CONRACTOR TELSET BACK YARD HWY PROP LINE WIDTH
Compensation provisions Of the Labor Code, you must forthwith � dA/!1 Z4-4FRONT
F
comply with such provisions or this permit shall be deemed revoked. AD ESS LI .N F L 7-+
LICENSED CONTRACTORS DECLARATION /��� SIDE AC a IL
LICENSED � ! LIC.CLASS ® P L Fit•L•T e V CJ
I hereby affirm that I am licensed underprovisions of Chapter 9 V
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO OF AMILIES SEWER MAP 3303 1437 jig x
Professio17
ns Code,and m license is in full force and fect. Q NEW , BK PG , �Oi i�� C
License Number v LiC.CIaS5�t DESCRIP ON OF WORK ADD ❑ VALUATION ,�`(
Contractor Date 7 V V j Mr-e $ G a.�) enn C�� 2 ITEMS W
ALTER ❑
TOTAL
REPAIR ❑ a.
'.�
❑ 1 am exempt under Sec. $ CHECK/K I/
Va_u[T e
B.BP.C.for this reason DEMOL ❑ [rLDMA P/C#
Date: USE OF EXISTING BLDG. URM 13 ^�.CHRANGE s�j+S�a U`r"i I
Signature APPLICANT(PRINT) TEL NO. LDMA Perm# JV �
[3I, as owner of the property, or my employees with wages as Z
their sole compensation, will do the work and the structure is ADDRESS 0
not intended or offered for sale (Section 7044, Business and FINAL DATE a � Qy, ;(
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL Ill-CHECK �}
11 I, 8S owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ('Z
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY CHANGE v0
licensed contractors to construct the project (Section 7044, YEs❑ No❑
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 8/
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FORQ�—�Jt�u If O:
GUIDELINES
I hereby affirm that there is a construction lending agency for YES❑ NO❑ 9764 AN 9°10
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.
TITLE 2.CHAPTER 2 20 SECTIONS 2 20 100 THRGH 2 20 140
@ Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PRM T FROM THE SCAOMD.CONCERNING HAZARDOUS
O
Lender's Address
('�() OWNER ON AGENT
I certify that I have read this application and state under penalty t IN
0 of perjury that the above information is correct.I agree to comp P.C.FEE/ ./ 7. 9f PERMIT FEE ��.�
with all county ordinances and State laws relating to buildi �f14
m construction, and h eby authorize representatives of this County ISSUANCE FEE
to en on the -mentioned property for inspeF�tion rposes. 7-7 -30
`f' - �J6 INVESTIGATION FEE TOTALF 4
7 l / 7
GpmtmA d App`+CON a Aw" - !®
SEE REVERSE FOR EXPLANATORY LANGUAGE