HomeMy Public PortalAbout6610 OAK AVE_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS kP3E4.Ers-r`t;, , �•�*" •- BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUIP)Ni��ESS
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS (�P(�
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) CITY ZIP
LOCALITY
Policy NO. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. 60 X 16ANEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT +314 ,1
3 BLOCK LOT NO. '
department. USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOO PAGER PARCE
Z FJJ i V f3— I SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER T L NO. YES NO
COMPENSATION INSURANCE + oZ WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred ADDRESS
DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.)
CITY
I certify that in the performance of the work for which this permit L 7
is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws. ARCHI CT OR EN INEER TEL NO.
- - STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT If, after making this Certificate of 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 SIDE
CITY LIC.CLASS PL
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with'Section 7000)of Division 3 of the Business and SO SIZE NO.OF :RIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. /M NEW ❑ BK. PG 1 >-
DESCRIPTIONAno OF WO�iK I� VALUATION ® ACC:T 3 o
License Number Lic.Class / , ADD r
Contractor Date J ALTER ❑ $ '�® 3303 1041.50
❑ 1 am exempt under Sec. Iq REPAIR ❑ $ ; 1 ITEMS o
BAP.C.for this reason J DEMOL ❑
"I.. . , 1?n LDMA PIC# TOTAL .'1041.50 W
Date: S OF EXISTI BLDG. t URM ❑ HEC�S 1041:50 W
_/$IgnatUre APPLICANT( ) L NO: LDMA Perm# rC .013 Z
MLQ I, as owner of the.property, or my employees with wages as 0 r x,41.V
their sole compensation, will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and (D�O LIE FINAL DATE r~`�
gAl�rofessions Code.) p 1r
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J A
as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q +�
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY �/
licensed contractors to construct the project (Section 7044, YES❑ No❑ VI it AL 1 �3 °19
Business and Professions Code.) L/ HE��i 1��]5.1
WILL THE INTENDED USE OF THE BUIDUNG 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 CHECKLIST FOR
GUIDELINES CHANGE .00
I hereby affirm that there is a construction lending agency for YES❑ NO❑
CM the performance of the work for which this permit is issued(Sec. :
m I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
N o000- 01 11/30/45
3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
j TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS
Lender's Name I MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
o Lender's Address 3501 1 AM- 9:54
p OWNER OR AGENT
oI certify that I have read this application and state under penalty P.C.FEE O� PERMIT FEE
O of perjury that the above information is correct.I agree to comply
$ with all county ordinances and State laws relating to building
;g construction, and hereby authorize representatives of this County ISSUANCE FEE 9 v
to enter upon the above-m tinned P t for inspection purposes.
10 INVESTIGATION FEE TOTAL FEV -2 / /
P. .�Wa a Appli=t«Avg Deb o% (p
SEE REVERSE FOR EXPLANATORY LANGUAGE