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Home My Public Portal About9935 OLIVE ST_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILD_ As✓ I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS or a certificate of Workers'Compensation Insurance,or a certified 46155 &Lat S Ave 0.0 T- 0 copy thereof(Sec.3800,Lab.C.) c CITY�M�Le G/.�../ ZIP Ar��O LOCALITY Policy No Com✓ rCOmpany r SIZE OF LOT L NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. ZSZ 4 NEAREST CROSS ST. 51 Certified co Is filed with the count building TRAA BLACK LOT NJI0 USE ZONE MAP NO. PY� y g inspection __11 (7 C7 1 1 „ departm� department. 161 FYI Date �! � pplicant A �� ASSESSOR MAP BOOK PAGE PARCEL 65 I Q 14 j5 27�$ SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE owFM imPM&P07090 600560-034S WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) At-PtaIItJ AVrM I certify that in the performance of the work for which this permit CITY /h�NTE zIP al 17 3) is issued, I shall not employ any person in any manner so as to OIRlENGINEERG TEL NO. become subject to the Workers'Compensation Laws. ARCHITECT 14cme � GI*Trm STATISTICAL CLASSIFICATION APT Y CONDO Date Applicant ADDRESS CLASS NO. DO DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of P.D• X 1740 ep A?-(VjA CA -1l 1m Z REQUIRED TOTALS CK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PpArf!lp.9. WIDTH Compensation provisions of the Labor Code, you must forthwith A&7 r * ®µ71{e FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL 3.303 328 50 LICENSED CONTRACTORS DECLARATIONSIDE CITY LIC.CLASS P L 1 1 hereby affirm that I am licensed underprovisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO,OF STORIES NO,OF FAMILIES SEWER MAP '°9 Professions Code,a,nq my license is in full force and effect. 2 15© I I NEW IV BK PG ® 3303 2066°70 D}„ Lic.Class � DESCRIPTION OF WORK ADD ❑ VALUATION I 1 V O ITEMS License Number W , °�. Contractor �� Date '4 "�y— 9.9 RIF-PAIR ALTER El TOTAL �39 ° 0 ❑ 1 am exempt under Sec. O� OHEGN39L°�D BBP.C.for this reason DEMOL 11 v Date: USE OF EXISTING BLDG. URM ❑ LDMA P/C# CHANGE °00 a Signature APPLICANT(PRINT) TEL NO. LDMA Perm# z ❑ I, as owner of the property, or my employees with wages as �T / �e 0 0000-0001 ?/14/9b their sale compensation, will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and FINAL DATE Q 4851 1 AM 9:59°5q Professions Code.) HALL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 2 ❑ 1, as owner of the ORA MIXTURE CONTAI G A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE property, am exclusively contracting with AMOUNTS SPECIFIED 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 BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANA ENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR D 23 GUIDELINE! � 1 hereby affirm that there is a construction lending agency for D 0 ACCT°% YES❑ NO a a the performance of the work for which this permit is issued(Sec. w (HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUID N MD PERMITTING ;;�-I a 3DJ7,CIV.C.) CHECKLIST I UNDERSTAND M�R,�I'ES OUIR ENTS UNDER GE COUNTY CODE, .7'��i1058-92 TITLE 2,CHAPTER 2 20 SE 2. ROUG 20 CON ING HAZARDOUS ITEMS Lender's Name , �� •tn MATERIALS REPORTING A F N FR MD. Ny� 1 ITEI IS 0o Lender's Address / { C OWNER OR AGENT TOTAL 1058-92 c I certify that I have read this application and state under penalty F 8 2 of perjury that the above information is correct.I agree to comply C.FEE �� PERMIT FEE y,1 CHECK 10�J+�°��- N with all county ordinances and State laws relating to buildin // L/ A °00 construction, and hereby representatives of this County 2a p r�, ISSUANCE FEE �r/ 0 4HrINGE m to enter upon the abo d property for inspection rpos ,J O �l V n p° INVESTIGATION FEE TOTAL FED 5/221/95 SEE REVERSE FOR EXPLANATORY LANGUAGE ry 7_e f3'� 1 Art 9:54