The URL can be used to link to this page

Home My Public Portal About5827 OAK AVE_Building__ y • • APPLICATION FO R,, BUILDING PERMIT -r COUNTY OF LOS ANGELES BUILDING AND SAFETY 1 � WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BIALDING�RE I hereby affirm that I have a certificate of consent to self Insure B UILDINGADORE Ae or a certificate of Workers Compensation Insurance or a certified _,_ 0copy thereof(Sec3800 Lab C) LOCALITPolicy No CompanyOT NO OF BLDGS NOW ON LOT❑ Certified Copy 13 hereby fumLshed NEAREST CROSS ST ❑ Certified copy is filed with the county building Inspection BLOCK LOT NO department USE ZONE MAP NO Date Applicant ASSE3SO7z- BOOK 31G w� PARCEL 7 3 S SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS E 'j' TEL NO YE (� COMPENSATION INSURANCE �.raftl gggg v�S a 8�p i Z WITHIN 1000 FT OF SCHOOLSs No (This section need not be completed If the permit is for one hundred � a A#e- dollars($100)or less) a DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY 1 certify that In the performance of the work for which this permit C e C ZIP 70 �Apf 3 Is Issued I shall not employ any person m any manner so as to ARCHITE OR ENGINES TEL NO become subject to the Workers Compensation Laws STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO 0/ DWELL UNITS NOTICE 7O APPLIC4NT If after making this Certificate of REOUIRED TOTAL SFFJPM EXIST Exemption you should become subject to the Workers CON TEL NO SET BACK YARD HWY SFM P WIDTH Compensation provisions of the Labor Code you must forthwith FRONT 3303 37 comply with such provisions or this permit shall be deemed revoked 1ADDRESS LIC NO PL LICENSED CONTRACTORS DECLARATION SIDE 1 crlY uc ctAss P L I hereby affirm that I am licensed underprovisions of Chapter 9 EWER MAP ■37 (commencing with Section 7000)of Division 3 of the Business and SO FT SIZE NO OF RIES NO OF FAMILIES Professions Code and my license is 1n full force and effect as NEW GV BK PG , OEC( 12b3.37a DESCR ON OF WORK ADD ❑ VALUATION License Number LIO Class CHANGE •000 Contractor Date s ALTER ❑ $ V ❑ 1 am exempt under Sec REPAIR ❑ $ COW-MI $/ 81/990 BBPC for this reason DEMOL ❑ tL 6N 7n Date USE OF EXISTING BLDG URM ❑ LDMA P/C# 1746 1 f t 1 5-2 3O W Signature APPLICANT(PRINT) TEL NO LDMA Perm# _ Z ❑ 1 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 rat Intended or offered for sale (Section 7044 Business and FINAL DATE G Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL r ❑ I a3 owner of thepropertyam exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY licensed contractors to construct the project (Section 7044 YES❑ NO❑ f A Business and Professions Code) 1 WILL THE INTENDED USE OF THE BUIDIJNG BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKUST FOR GUIDELINES t I hereby affirm that there Is a construction lending agency for YES 13No❑ N the performance of the work for Which this permit is Issued(Sec 01 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 A/►/►�' a Al TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS �py�•T 15M.57 G7 i Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD =3 •J! o Lenders Address C ovmg.P OR AGENT GI certify that I have read this application and state under penalty 1 ITM C of perjury that the above information is correct I agree to comply PC FEE / �� PERMIT F Q e w TOTAL •�7 N with all county ordinances and State laws relating to building (O �[ construction and hereby authorize representatives of this County ISSUANdE FEE �yFy Zn Cr'� m f to enter upon the above mentioned property for inspection purposes �7 30 OECK 1SM• ro INVESTIGATION FEE O 4f B 1NGE .00 m Sig n I Applin a AAs t Nat .57 SEE REVERSE FOR EXPLANATORY LANGUAGE nnnn_nnn� a/ 7/A�