HomeMy Public PortalAbout9939 OLIVE ST_Building__ APPLICATION FOR BUILDING PERMIT
• COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION
FOR APPLICANT TO FILL IN BUILDING D SS
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS w7'
$ •'��
or a certificate of Workers'Compensation Insurance,or a certified 141M OLIVE AVE
copy thereof(Sec.3800,Lab.C.) CITYet 7--/ ZIP41,79
0 LOCALITY
Policy No_r zo?6z Company SIZE OF LOT NO.OF BL DGS.NOW ON LOT
❑ Certified copy is hereby furnished. &.05 3
NEAREST CROSS ST.
�kCertified c py is filed with the county building inspection TRACT c BLOCK LOT NO.
dep�a7rt [t/. 51C1�5 LPT � USE ZONE MAP NO.
e� �7 Applicant_ e�ds� ASSESSOR MAP BOOK PAS /PARCEL Za SPECIAL CONDITIONS
Date i7 �a
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNERTEL NO. "d�
COMPENSATION INSURANCE DA)Gl1) �6V lopm T' 06).150,03545 WITHIN 1000 FT.OF SCHOOL? YES NO
This section need not be completed if the permit is for one hundred ADDRESS
( P P 42?� 95^A-VW qN A✓� 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 07BNM zl q I?311
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO.
become subject to the Workers'Compensation Laws. �.J Gvs�� �f6N 5 `� mesas. STATISTICAL CLASSIFICATION Pf� CONDO
nt
NOTICE TO APPLICANT. If,If, after making this Certificate of ADDRESS NO✓ Z,SA' G� �,�� CLASSQINIOE DWELL UNITS At- :f°D TOTAL SHM&ROM EXI 59
Exemption, you should become subject to the Workers' CONTRACTOR l' TEL NO. SET BACK YARD HWY P P LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith 1V012—' FRONT
comply with such provisions or this permit shall be deemed revoked. R ADDRESS LIC.NO. PL ACCLIA,
LICENSED CONTRACTORS DECLARATIONIt CITY LIC.CLASS P L SIDE
I hereby affirm that I am licensed underprovisions of Chapter 9 ER MAP 3303 190731
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO,OF STORIES NO,OF FAMILIES ? ITEMS
Professions Code,and m 11 in full force and effect. ZdSo L / NEW EpBK PG TOTAL101°90 CL
LicenseNumber i �7 Lic.Classy 49! DES �ON�OF WORK R ADD ❑ VALUATION �p ® Q
Contractor G 2�—�'/' Date �`',�y� W ALTER ❑ ��/ CHECK 2101.900
❑ 1 am exempt under Sec. V REPAIR ❑ /��— ��� Of+ CHANGE Do p
BAP.C.for this reason DEMOL ❑ b
Date: USE OF EXISTING BLDG. URM ❑ LDMA P/C 0000-0001 21/14/9fs a
co
Signature APPLICANT(PRI ) `C A$0v� Z TEL NO. LDMA Perm 8 4V853 1 AM 10:00 z
El 1. as owner of the property, or my employees with wages as ✓ O
their sole compensation, will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DATE, C
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
❑ I, as owner of the property, am exclusively contracting with 110-
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE FINAL BY •
AMOUNTS SPECIFIED ON HAZARDOUS MATERIALS INFORMATION GUIDE?
licensed contractors to construct the project (Section 7044, 23
VES ElNO .+.
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING £ .9.
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ACC i°-a
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGE DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES I 330,+ 10125.93
I hereby affirm that there is a construction lending agency for VES❑ NO I D O
w the performance of the work for which this permit is issued(Sec. 1 ITECI IS
3(197,CIV.C. I HAVE READ THE HAZARDOUS MATER INFORMATION GUIDE AN SCAQMD PERMITTING I
a ) CHECKLIST I UNDERSTAND MY REO EMENTS UNDER-1111.
G S COUNTY CODE, ('�n�°(�a
TITLE 2,CHAPTER=20N .20.1 0 THRO NING HAZARDOUS OT 1025 -2Lender's Name � � C MATERIALS REPORM T I TOTAL
oLender's Address CHECK 1025.93
O OWNER OR AGENT
c I certify that I have read this application and state under penalty CHANGE °00
4 of perjury that the above information is correct.I agree to comp P.C.FEE C PERMIT FEE (�GD.10 f
N with all county ordinances a State laws relating to build) c /V Q
construction, and hereby epresentatives of this Cour y ISSUANCE FEE
m to enter u n the 95
abo to roperty for inspection p pose //Y.
• :30 a ��_�(��1 j ?/
m INVESTIGATION FEE TOTAL FEE 0041 1 Art 9:54
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SEE REVERSE FOR EXPLANATORY LANGUAGE