HomeMy Public PortalAbout10209 OLIVE ST_Building__ . . , If APPLIcAtiOIV F®R ILDiNG PERMIT
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COUNTY OF LOS ANGELES . BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby.affirm that I have a certificate of consent to self insure, BUILDING ADDRESS e �op�L a. • CC,//f �
or a certificate of Workers'Compensation Insurance,or a certified I�.
copy thereof(Sec.3800,Lab.C.) CIT ZIP
Policy No. cz= LOCA ITY Company SIZE OF
L.OT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. 90,-'t-111, NEAREST CROSS 19T.
❑ Certified copy is filed with the county building inspection TRACT BLACK LOT NO.
department. SESSOR MAP O ` PAGE PARCEL USE ZONE MAP N j I �/
Date Applicant SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' QW J D TEL NO.
COMPENSATION INSURANCE A 18.4 43-co 0119 WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred, DDR
dollars($100)or less.) °��p S . - Q,ie• i DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
9'
• '
CITY^ ZIP
I certify,that In.the performance Of the work for which this permit;
is issued, I shall not employ any person in any manner so as_to I ARCHITECT OR ENGINEER 'i TEL NO. �� ✓ V
become subject to the Workers'Compensation Laws. '
I s 18 3 6o STATISTICAL CLASSIFICATION L / APT CONDO
Date Applicant' i ADDRESS w CLASS NO.� DWELL UNITS L�
NOTICE 70 APPLICANT If, after making this Certificate 1,bf; b 1 �+ • REQUIRED TOTAL SETBACK FROM EXIST
Exemption,, you should become subject to the Workdrs'I CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of,the Labor Code, you must forthwith, i FRONT ��
comply with such provisions or this permit shall be deemed revoked.: ADDRESS LIC.NO. F I• i.
LICENSED CONTRACTORS DECLARATION ! °. SIDE fy roF
�' '• CITY
I hereby affirm LIC.CLASS I PL
that I am licensed underprovislons of Chapters 1
a ' SEWER MAP ,,_iJL j_ I;
(commencing with Section 7000)of Division 3 of the Business an SQ.FT.SIZE NO.OF S70RIES NO.OF FAMILIES 5.u34
,
Professions Code,and my license is in full force and effect. i / NEW I' BK PG ® r. }
ITEMS a
License Number Lic.Class I DESC IPTION O WOR( ADD ❑ VALUATION Q
Contractor Date fl ALTER ❑
16 9 0 0 TOTAL
L 1-265.30
De I am exempt under Sec. REPAIR ❑ CH 261:.1 J-201
B.&P.C.for this reason. ! DEMOL ❑• �:��!�fN E °
LDMA P/C
Date: a.I; Y USE OF EXISTING BLDG. y LU
URM ❑
Signature i' ": �'�•'
AM I l 'i {%
+ IL
APPLICANT(PRINT) TEL Na LDMA Perm+e` '�10 111 5/91Z
'��' �
r:
❑ I, as owner of the property, or my employees with wages,as z elan'
their le compensation, will do the work and the structure is ADDRESS p
no mended or offered for sale (Section 7044, Business`nd FINAL DAT a ' ' '�+,)) j` 1533.0-6
fessions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL N +k �T
I, as owner of the property, am exclusively contracting Wlth OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 1 Q a: 3 I E 1i�
licensed contractors to construct the project (Section 7044, AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY t,t L
Business and Professions Code.)
YES 11 NO 1:1 WILL THE ILDING I sL 'L .6.06
NTENDED USE OF THE BUIDNG BY THE ICANT OR
I,
OCCUPANT IREQU RE A PERMIT OR CONSTRUCTION OR MODIFICATION FROM RTHE USOUTH I E HE SC J v[16,CONSTRUCTION LENDING AGENCY i COAST AR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST OR
GUIDEUNE3. 1-7
L•g I�.{
I hereby affirm that there is a construction lending agency, forES CHECK
y ❑ No❑ H K
the performance Of the Work for WHICh this p2rmlt IS ISSUed(SBC. IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING cm
�•�"IANIGE "LLL
a 3087,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, +
Lender's Name TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS
MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
a Lender's Address IY!"t,(E_I'3I1i y:i t} ,1Lf
O 5 OWNER OR AGENT J•.r
c I certify that I have read this application and state'under penaltyll ja1f,
0 of perjury that the above information is correct.I agree to comply P.C.FEE / PERMIT FEE / i AM
Or with all county ordinances and State laws relating to building /�� �•
m. construction, and hereby authorize representatives of this Codnty ISSUANCE FEE �Jr
ton r p the above- Honed property for inspection purposes.
n �� S INVESTIGATION FEE TOTAL FEE
fur MPWxM-AWn: yjo.3
SEE REVERSE FOR EXPLANATORY LANGUAGE