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�' • ' ► •• APPLICATI®N.F613 -BUILDING PERMIT
COUNTY OF LAS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION F013 APPLICANT TO FILL IN BUILDING ADDR S ,
I hereby affirm that I have a certificate of consent to self insure, FSIZE
gDD SS v
or a certificate of Workers'Compensation Insurance,or a certified $ `
copy thereof(Sec.3800,Lab.C.) C LOCALITY
Policy No. Company L NO.OF BLDGS.NOVON LOT r'7e❑ Certified copy is hereby furnished. f 120
!-� NEAREST OSS S.
❑ Certified copy is filed with the county building inspection TRACT�O�p-n BLOCK. LOT NO.�, J fiy of Ve
department. �J ?�� f USE ZON P NO.
Date Applicant ASSESSOR MAP. OPAGE PARCEL
4A.59-5- 002— 0 1 SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER f`1 _Al J�r� j �Z TE
L NO YES 70-t-/
O /, /`•" (J
COMPENSATION INSURANCE qE\�C7Y� 17 / � WITHIN 1000 FT.OF SCHOOL? (�
(This section need not be completed if the permit is for one hundred ADD j�![, ����� �-,
dollars($100)or less.)
! t7 DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
CITY ZIP Q
1 certify that in the performance of the work for which this permitln 7
is issued, I shall not employ any person in any manner so as to ARCHITECT,J ENGINEER TEL
NO.
become subject to the Workers'Compensation Laws. S L�,� /• /L� j z-�P 7� STATISTICAL CLA IFICATION APT CONDO
Date Applicant ADDR SS �r (/(/ 3 CLASS NO. / DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate of J� �i r Ale, REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject t0 the Workers' CONTRACTOR /�' TEL NO. SET BACK YARD HWY PROP GN_E: WIDTH r•_
Compensation provisions of the Labor Code, you must forthwith e,4_ !i(/ FRONT y
comply with such provisions or this permit shall be deemed revoked. ADD SS LIC.NO. PL
LICENSED CONTRACTORS DECLARATIONSIDE _ T
CITY LIC.CLASS PL
I hereby affirm that 1 am licensed underprovisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO..OF STORI S NO.OF AMILIES SEWER MAP
Professions Code,and my license is in full force and effect. NEW ❑ BK PG ® "-: -�_: -}
License Number Lic.Class DESC IRTI N OF WORK ADD } VALUA O
Contractor Date I e ALTER ❑
❑ I am exempt under Sec. $ �' 9 Q Q _ _
REPAIR C10 :Y,•: :_
B.BP.C.for this reason DEMOL ❑ LDMA P/C# -C.:
_
Date: U E OF EXI ING G. ]��✓� URM ❑ - U
,/,Signature APPLI A (PRINT) �J TEL NO. LDMA Perm# ._' z
L"J I, as owner of the property, or my employees with wages as ��� L /" 2�•S �— Z ••-
their sole compensation, will do the work and the structure is ADDRESS O
� I t.
not intended or offered for sale (Section 7044, Business and FINAL DATE
Professions Code.)
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL r
1, eS owner
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
licensed contractors to construct the project (Section 70444, J "•-`i=}_
❑ Of the property, am exclusively contracting 4AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL
, ,.
Business and Professions Code.) VES 11 No❑ F.- 1 - 64
WILL THE INTENDED USE OF THE BUIDLING 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 z�s
I hereby affirm that there is a construction lending agency for YES❑ NO❑
c4 the performance of the work for which this permit is issued(Sec.
I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING
a 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LAS ANGELES COUNTY CODE, ^,
TITLE 2•CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20.140 CONCERNING HAZARDOUS '•t"• r {•, =/r.• ,+ T
3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 1-Ir .. ,, _.
o Lender's Address -
,I - 1 !' . p. ..
C OWNER OR AGENT - - ,. -
c I certify that I have read this application and state under penalty
0 of perjury that the above information is correct.I agree to comply P.C.FEE ,g., PERMIT FEE
M with all county ordinances and State laws relating to building 7 c/� •
construction, and hereby authorize representatives of this County ISSUANCE FEE
ato enter upon the above-mentioned p ray for inspection purposes. � � q lL�• 7"
2 _ INVESTIGATION FEE TOTAL-
n:lum of App-Lnl A�
SEE REVERSE FOR EXPLANATORY LANGUAGE