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Home My Public Portal About9129 OLEMA ST_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF i Q$ 'OGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDI ADDR S I hereby affirm that I have a certificate of consent to self insure, BUILD /PDDRS or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) �^ CITY ZIP 7 sr Policy No.MM&gam ,--0��Company S��l� r��D G� L� C T 9t/ v d LOCALITY SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. I NEAREST CROSS ST ❑ Certified copy is filed with the�ounty building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. Date//e� Applican r ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE aO, QD501- WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS dollars($100)or less.) Lr/-9 A DISTRICT GROUP TY CONST. FIRE ZONE PROCESSED BY CITY ZIP I certify that in the performance of the work for which this permit LG- C[ T 7 is issued, I shall not employ any person in any manner so as t0 ARCHITECT OR ENGINEER TEL NO. become subject to the Workers'Compensation Laws. 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 &(„E X0060-6 Sbr A,9 S 00 FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION63.?-'7c°? 41 41 YfA fi-1/c` -mg,:0 SIDE CIT Too LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 1 &71 PZ-tr C-f G— (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STURIES NO.OF FAMILIES SEWER MAP 3303 142.20 Professions Code,and Gmy license is in full force and effect.�y NEW BK PG ® 1 ITEMS d License Number /3S-11' Lic.Class C 2-39 DESCRIPTION OF WORK ADD ❑ VALUATION Contractor 42A64e- &-060-10 Date /!.Z-`!'� SifiAetN re-y F temy&&& ALTER ❑ $ TOTAL. 142--20 U ❑ I am exempt under Sec. GJovD 5414REPAIR ❑ CHECK 14�n?0 0 B.&P.C.for this reason L 6F �2 Ll�G DEMOL ❑ $ CHANGE aCOv LDMA P/C# 111 Date: USE OF EXISTING BLDG. URM ❑ nn n M Signature APPLICANT(PRINT) TEL NO. LDMA Perm# 0000-0001 11/ 1/95 co ❑ I, as owner of the property, or my employees with wages as Z their sole compensation, will do the work and the structure is ADDRESS O 3095 1 Ali 9-37 not intended or offered for sale (Section 7044, Business and FINAL DATE a Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ I, as owner of the property, am exclusively contracting with 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 BUIDUNG BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ NO❑ Cy the performance Of the work for which this permit Is Issued(.Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING a 3097,CIV.C.) CHECKUST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, CM TITLE 2,CHAPTER 2 20 SECTIONS 2.20.100 THROUGH 2 20 140 CONCERNING HAZARDOUS iLender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. in Lender's Address GINNER OR AGENT O c I certify that I have read this application and state under penalty of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE N with all county ordinances and State laws relating to building �f m construction, and.hereby authorize representatives of this County ISSUANCE FEE �g 2 0 Cl) to en a upo h '! ove-mentioned property for inspection purposes. pf ►Z INVESTIGATION FEE TOTAL FEE n Sgn-A o 1 ~crl Dui SEE REVERSE FOR EXPLANATORY LANGUAGE