HomeMy Public PortalAbout9111 OLEMA ST_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING ADDRESS
WORKERS COMPENSATION DECLARATION ■+I
GG DD ESS
I hereby affirm that I have a certificate of consent to self Insure, BUILDIN�� 0L e1M u S / ®l 14i
or a certificate of Workers'Compensation Insurance,or a certified C.
copy thereof(Sec.3800,Lab.C.) ClY�-�-- ZIP ®,��o LOCALITYJ
Policy No. Company SIZE OF LOT NO.OF BLDG3.NOW ON LOT ��
C1 Certified copy is hereby furnished. NEARESZy
T C
Z.
❑ Certified copy is filed with the county building Inspection
TRACT BLOCK LOT NO.
USE ZONE MAP NO.
department.
Date Applicant ASSESSOR MAP BOOK 2 ®9 a/ PARCEL SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER /,�,��` S. �j�(IO) NO r o y YES NO
COMPENSATION INSURANCE (�® J ��• �O~ WITHIN 1000 FT OF SCHOOL?
ADDR 9 -�
(This section need not be completed if the permit is for one hundred �I OLem at 57- DISTRICT GROUP TYPE CONYST.' FIRE ZON PROCESS BY
dollars($100)or less.) ClTv� ZIP 9��a® 0
I certify that in the performance of the work for which this permit / 81 , k �3 1•
is Issued, I shall not employ any person in any manner so as to ARCHI ENGI ��0. r
become subject to the Workers'Compensation Laws. _ 0 11 1)6d STATISTICAL CLASSIFICATION A DO
Date Applicant Q�Q ^r�a /• 0. CLASS NO. DWELL UNITS
NOTICE TO APPLICANT: If, after making this Certificate of f-a TEL NNOO.. REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' OR SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code,you must forthwith FROM
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL ,
(� !.'(/v i }
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS SIDE PL A r r•T s O
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP c2
SQ.FT) E NO.OF STORES NO.OF FAMILIES :1 �
(commencing with Section 7000)of Division 3 of the Business and TrE NEW ❑ BK PG �I�7 3 °x,40
Professions Code,and my license is in full force and effect. y
D CR ION OF R ADD ❑ VALUATION 0 b 1 j TE+I�� W
License Number Lia Class 7f dye r a
Contractor Date ALTER ❑ $ TOTAL 116 m Biz
❑ I am exempt under Sec.
REPAIR ❑ CHECK 116°��`_,—
B.BP.C.for this reason DEMOL ❑ . LDMA PIC# CHANGE °GO
Date: USE OF EXISTING BLDG. URM ❑
,Signature APPLI PIT(PRINT) /1/ LDMA Perm# (�i(la l-A001 6/ 6/5",
1 as owner of the property, or my employees with wages as r� S . S. 4.S�uR �° !0 r` f �p }7
their sole compensation,will do the work and the structure is ADDR v lu FINAL DA a 11�t 1 AM 8:53
not Intended or offered for sale (Section 7044, Business and
Professions Code.) WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL j
❑ I, eS owner of the roperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN
P Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project (Section 7044, YES❑ NO❑
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH
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 YES❑ NO 11the performance Of the work for which this permit IS issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD
3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES
COUNTY CODE,TITLEZ CHAPTER 220 SECTIONSZ20.100THROUGH IM140 CONCERNING
Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
Lender's Address
OWNM OR AGEPIT
0 1 certify that I have read this application and state that the above PC.FEE PERMIT FEE 2,
Information is correct. I agree to comply with all county 4 J
ordinances and State laws relating to building construction,and
53
hereby authorize rep entatives of this County to enter upon ISSUANCE FEE/ �)/I
the ove-men' for Inspection purposes. •(J V
f v ty 6- 6 9� INVESTIGATION FEE TOTAL FEE
^V1k uaAgOM oxa
SEE REVERSE FOR EXPLANATORY LANGUAGE