HomeMy Public PortalAbout10621 OLIVE ST_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILOQ�o �
BUI DIN D T
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) [TRACT
^-1•ZIP LOCALITY
Policy NQsn1^94 060544' Company 21ATP' R(aND IZE O LOT NO.OF B DGS N O N LOT ���
❑ Certified copy is hereby furnished. !S" l _ NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection 8698K-- T NO. USE ZONE MAP NO.
department.
ASSESSOR MAP BOOK PAGE PARCEL
Date �'aA 9 Applicant E[:!c FA2,ICAl�.gN adv• v� Q Qin
O v� SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' NER
COMPENSATION INSURANCE )S - _VIA r tf-) �- 2-0- WITHIN 11000 FT.OF SCHOOL? YES No
completed if the permit is for one hundred ADDRESS
(This section need not be com
P tU �`E t } DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY ZIP
is issued, I shall not employ any person in any manner so as to J
become subject to the Workers'Com ensation ws. ARCHITECT OR ENG ER J TEL NO.
1 hvn G _ STATISTICAL CLAS FICATION APT CONDO
Date'+"�/'9SrApplicant �r4l"'. .Cre ADDRESS �} 6 CLASS1— DWELL UNITS
APPLICANT. /
NOTICE TO APPLICANT. If, after making this Certificate Of CJ �� r ✓'E 2- REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' COON RAC70R 25Y�. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith dYr., I�d V . -u0 FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL
LICENSED CONTRACTORS DECLARATION s-` S? 7 �, &7/S SIDE
CITY LIC.CLASS PL
I hereby affirm that I am licensed underprovisions of Chapter 9 JGrir- M O E 43-/ _
(commencing with Section 7000)of Division 3 of the Business and SEWER MAP -
SQ.FT.SI _ NO.OF STORIES NO.OF FAMILIES NEW �'� BK PG ..ul�� `����'�°,_�
Professions Code,and my license is in full force and effect. �. I , Il
Lig nse Number 40'3/3 Lic.Class r DEERIPTION OF WORK �+ n ADD ❑ VALUATION L �1•J O
Contractor or DSIlLL07°l4EJVJ'Date 3-94-Ti- +��-:� J{ (plo— t'Yl ALTER ❑ ` �C '€I I H� i-'.
` I C REPAIR ❑ HEC'K i �I ■i
❑ I am exempt under Sec. CHANGE °'SIF
B.BP.C.for this reason r p CGC '� DEMOL ❑ LDMA P/C
Date: USE OF EXISTING BLDG. URM ❑ IL
roiDSignature , tic'`� �
APPLLL/IIIGGG�WWWT(PAINT) �� IEL NO. DMA Perm f1=1Ls1)-_li'iJf t 1f t:�, R`z
❑ I, as owner of the property, or my employees with wages as ` - C� - Z Z i r;
their sole compensation, will do the work and the structure is ADDRESS / �, O to r,I y;?;I
not intended or offered for sale (Section 7044, Business and kw � �' �►C ' 14 -01 a i
"F-(NAL DA ���� / G "vl iv i f:'wt r f
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL of J I 1 EM3
❑ 1, as owner of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project (Section 7044,
YES NO L� I!EIi�L 3ij�-L'aiJ:r
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK 1-i�i p'•�
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH /, i f.7.e a•b
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR CHANGE
, t.)i
GUIDELINES. /t �• GE (.
I hereby affirm that there is a construction lending agency for YES❑ NO)Z (�
C4 the performance of the work for which this permit is issued(Sec. t31NF6RMAno GUIDE AND THE SCAQMD PERMITTING I
p1 I HAVE READ THE HAZARDOUS MATERIA
3097,CIV.C.) CHECKLIST.I UNDERSTAND M]LREQOrAgMBNY$UN R THE LOS ANGELES COUNTY CODE, I, {{' i�( - r•�.,;f C
TITLE 2,CHAPTER 2.20 CTION3 p-00 0 CONCERNING HAZARDOUS L LI4.jV J_IIJ i
Lender's Name MATERIALS R BFO}(OBTAINING AJITHE SCAQMD. tr I�
IL Lender's Address 7=`�� Ail °
o
o i certify that I have read this application and state under penalty 1-9-
with
c of perjury that the above information is correct.I agree to comply P.0 FEE /��, -/� PERMIT FEE
M with all county ordinances and State laws relating to building �7' _/
construction, and hereby authorize representatives of this County ISSUANCE FEE
ato entet upon the above-mentioned property for inspection purposes. �p-
m � _
INVESTIGATION—FEE TOTAL,71 /
r Sblria,°01 APPU=t a Ap°r Wb �O ,
SEE REVERSE FOR EXPLANATORY LANGUAGE