HomeMy Public PortalAbout9532 OLIVE ST_Building__ APPLICATI®.N. F®R BUILDING PERMIT
0.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR IPPLICANT TO FILL IN BUILD G ADDRESS
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS ��
or a certificate of Worker;Compensation Insurance,or a certified 01 5S S'T
copy thereof(Sec.3800,Lab.C.) CITY-rE/1PIE
Gr ZIP 1780
O�
Q LOCALITY ell
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT l L
❑ Certified copy is hereby furnished. NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL G�
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER _ TE / YES NO
COMPENSATION INSURANCE 7DSC O AP 4— (r'Z3 ITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred A RESS
dollars($100)or less.) OLIVE Sof' DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
I certify that in the performance of the work for which this permit CITY
-rS� I _ C/T ZIP /—R(09
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. L �o
become subject to the Workers'Compensation Laws. STATISTICAL CLAA�SS'IIFICATION 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' � � ,Q TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith ��� L4"ea- . 5,0 FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS '9J NO PL
LICENSED CONTRACTORS DECLARATION le) L� max- ��`��� SIDE
CLqr ee� LIC.CLAS PL
I hereby affirm that I am licensed underprovisions of Chapter 8 - `» SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES I NO.OF FAMILIES
Professions Code,and my license is in full force and effect. NEW 11 BK PG a
License Number Lic.Class DESCRIP I OF WORK ADD ❑ VALUATION C
Contractor Dated ALTER $ a
���
O
❑ 1 am exempt under Sec. Ael REPAIR El $ C
BAP.C.for this reason DEMOL ❑
LDMA P/C# � LL
Date: USE OF EXISTING BLDG. URM ❑ n
iV' U
ttt•t•T n
Signature APPLICANT(PRINT) TEL NO. LDMA Perm# �_ y,� C� L
11I, as owner of the property, or my employees with wages as Z 3313 '' n
their sole compensation, will do the work and the structure is ADDRESS O
not intended or offered for sale (Section 7044, Business and FINAL DATE Q0. 1 ITEMS
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J' � J TOTAL I( L y'j, v Wi
❑ 1, as Owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 184.9"t,P y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY r '1' P •I44 e i
licensed contractors to construct the project (Section 7044,
YES❑ NO❑
Business and Professions Code.) j��kEt 0
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING �' .00 L
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
I hereby affirm that there is a construction lending agency for YES❑ NO❑
m the perfOrmanCe Of the Work for Wt11Ch this permit IS ISSUed(SBC. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
a 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, (] i �*{ s
TITLE 2.CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS J903 1
46
i Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
0 Lender's Address OWNER OR AGENT
0
c 1 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 PERMIT FEE
$ with all county ordinances and State laws relating to building
construction, and hereb authorize representatives of this County ISSUANCE FEE
Q3 to enter u o e ab entioned property for inspection purposes.
,J 4 /79' INVESTIGATION FEE TOTAL FEE
� `Gyulun,of App',eyn or A¢nt �
SEE REVERSE FOR EXPLANATORY LANGUAGE