HomeMy Public PortalAbout6243 MUSCATEL AVE_Building__ . * , .I •� - : . , APPLICATION FOR BUILDING PERMIT �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION
FOR APPLICANT TO FILL IN BUILD1 ADDRESS
BUILDING DDRESS
I hereby affirm that I have a certificate of consent to self insure, iI/ LY If 17VAIV"V
or a certificate of Workers'Compensation Insurance,or a certified t J
copy thereof(Sec.380,Lab.C.) CITY • n ZIP `— LOCALITY
Policy No. Company SIZE OF LOT l� 0.OF BLDGS.NOW ON LOUT
11 Certified copy is hereby furnished. 5 p .t .-,L- NEAREST C ST
❑ Certified copy Is filed with the county building Inspection TRACTBLOCK LOT NO.
department. S USE ZONE MAP NO.
ASSESSOR MAP BOOK E PARCEL
Date Applicant SPECIAL CONDITIONS
i c ®111
CERTIFICATE OF EXEMPTION FROM WORKERS' W J �� TEL NO,
c � WI o00 .OF SCHOOL? YES NO
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the permit is for one hundred I c) A r L GROUP I TYPE CON FIRE ZONE PRXMED BY
dollars($100)or less.) CITY ZIP � a
I certify that in the performance of the work for which this permit t
Is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO.
ubj t0 the Workers'Compensation Laws. -'7 4417 Si STATISTICAL IF TION A C D
?,�bbwome
Ste pplicant ADDRESS ,y CLASS NO. DWELL UNITS
NOTICE TO PPLICANT. If, after making this Certificate of S `� r� REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code,you must forthwith FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL \
LICENSED CONTRACTORS DECLARATION i CITY LIC.CLASS SPL IDE a
I hereby affirm that 1 am licensed under provisions of Chapter 9 SEWER MAP
CJ
SQ.FT.SIZE NO.OF STORES NO.OF FAMILIES
(commencing with Section 7000)of Division 3 of the Business and _ � p
Professions Code,and my license is in full force and effect. 5 1 NEW ❑ Bk PG
License Number Lic.Class
DESCRIPTION OF WORK -G ADD VALVA N ® W
�
Contractor Date t` ALTER ❑ $
❑ I am exempt under See. REPAIR ❑
B.BP.C.for this reason `�L � DEMOL ❑ LD MA P/C N
Date: USE OFEXISTIN BLDG. URM ❑
Signature APPLICANT(PR(P7) TEL NO. d LAMA perm g 1
El 1, as owner of the property, or my employees with wages as i; SZ 4-7 1909 O a
their sole compensation,will do the work and the structure is ADDR .A( ^ 2
ACCT.
o a
not intended or offered for sale (Section 7044, Business end 5, G _,�- 7 FINAL DATE ® 3307 376.65
Professions Code.) WILLTHEAPPLICANTOR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL
❑ r0 B OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN T
1, as owner of the r r
p p rty, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY > !TCNS
licensed contractors to construct the project (Section 7044, YES❑ No
Business and Professions Code.) TOTAL 376.65
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIREA PERMIT FORCONSTRUCTION OR MODIFICATION FROMTHESOUTH CHECK
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST
FOR GUIDELINES.
I hereby affirm that there is a construction lending agency for Yrs 11 NO CHANGE .01-1
the performance of the work for which this permit is issued(Sec. I HAVE READ Tom{ R• [iIALS INFg� ON GUIDE AND THE SCAOMD
3097,Civ.C•)• �P6EgRUMI NG�CH�CK SST NDE Ib BGDIREMENTS UNDER THE LOS ANGELES
Lenders Name RiOTA y 7GH 220.14000NCERNING
IIp C GANDFOROBTAINITMROUMIT FROM THESCAOMD. I
J0OL-LGO1 6/22/90
Lenders Address
1428
1 AM 7:59
0 1 c fpi a s pi and state that the above �„
i orma n is correct. gree comply with all county RC.FEE -PERMIT FEE
onbrdm d Sta g to building construction,and
a h ';^ n of this County to enter up on I ISSUANCE FEE
as me ti ed party for IIS action purposes. f D
INVESTIGATION FEE TOTAL FEE V
6qn sso o/A9 vApont caro ..
SEE REVERSE FOR EXPLANATORY LANGUAGE
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FOR OFFICE USE FOR NLY APPLICANT O
TO FILL IN
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ARCHITECT OQ
No.or
NO.
101119.too.
BeTRACIE LINE
DESCRIPTION OF WORK
WAM;
I HEREBY ACKNOWLEDDIC THAT I HAVE MEAD TM?w*
.-777: APPLICATION AND STATE THAT THE ABOVE 18 COMMzcT IMA-PiA.T, 01.1jilli
ANKA _t:l)'lM:fA0
AND AORVC TO COMPLY WIT" ALL COUNTY ORDINANCES
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