HomeMy Public PortalAbout6019 PRIMROSE AVE_Building__ •.-= - �� APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDIN/G ADDRESS
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS . ' BUILD=
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) CITY ZIP ..
O LOCALITYi
Policy No. Company SIZE OF LOT O.OF BLDG&NOW OONLO `L
❑ Certified copy is hereby furnished. 1 ��� 1j—Q 7 NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection (,^J TRACT BLOCK LOT NO.
department.
USE ZONEMAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
_ SPECIAL CONDITIONS
TEL NO.
CERTIFICATE OF EXEMPTION FROM WORKERS' -y y YES NO
\ R
COMPENSATION INSURANCEio� o�/.� oZ/— /�d WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred ADDRESS �LI 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 CIz,Y �, ZIP 1~—, �!QD
is issued, I shall not employ any"person in any manner so as to AR TECT OR IN R /TEL NO. O
become subject t0 the Workers'Compen�slation/L/aw1s. J //1� n/ /e__ STATISTICAL CCLL,A�SfSIFFIICATION APT CONDO
/Date LgV100 Applicants/T / . X7'1 I=)7 l�iDl/S/S/, •�7�/'7 CLASS NO.�G� DWELL UNITS 741
NOTICE TO APPLICANT If,' after making this Certificate of �0 � REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Cade, you must forthwith FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL
LICENSED CONTRACTORS DECLARATION SIDE
CITY LIC.CLASS PL _
I hereby affirm. that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO,OF SJORIES NO.OFA FAM
Professions Code,and my license is in full force and effect. oma• OC NEW ❑ BK PG }
License Number Lic.Class DESC IGF WORK ADD ❑ VALUATION
�,— , IL
Contractor Date ALTER ❑
❑ 1 am exempt under Sec. - REPAIR ❑
B.BP.C.for this reason
DEMOL ❑ LDMA P/C# W
Date: USE OF EXISTING BLDG. URM ❑ IL
CD
Signature APPLICANT(PAINT) TEL NO. LDMA Perm# • 5 r t t'- '+ Z
'
El 1, as owner of the property, or my emZployees with wages as
j n
their sole compensation, will do the work and the structure is DRESS
O � TES,: _ 7
not intended or offered for sale (Section 7044, Business and FINAL DATE a '7 11 1- E.
ProfeSSIOrIS Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIALfro
❑ 1, as owner of theproperty, am exclusivel contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 7
Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY fi 4 �,670 n•7 1
licensed contractors to construct the project (Section 7044, ' a
YES❑ NO❑
Business and Professions Code.) r ' � ,�;�
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDINGt .-,-
OCCUPANT REQUIRE A PERMIT.FOR CONSTRUCTION OR.MODIFICATION FROM THE SOUTH r�iJlr�'7 $7h.]u
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR �,3 -
GUIDELINES. 1
I hereby.affirm that there is a construction lending agency for - YES 0 NO❑ 7 0080-000 j 121/ 511/01
athe performance of the work for which this permit is issued(Sec. Q _
I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING t •{ PM
(�)a !i
C4 3097,CIV.C.) CHECKLIST,I UNDERSTAND MY REQUIREMENTS.UNDER THE LOS ANGELES COUNTY CODE, �v(pi t 813136 1 f � 2:+.-t
UGH
Lender's Name MATERIALS REPORTITLE 2.CHAPTERTING AND FOR OBTAINING.20 SECTIONS 2.20.100TA PERM T 2FROM4THEOSCAOMD.GHAZARDOUS
0 Lender's Address
CI OWNER OR AGENT
o I certify that I have read this application and state under penalty
of perjury that the above information is correct.I agree to comply P.0 FE PERMIT FEE
N with all county ordinances and State laws relating to building 6 1. 3
construction, and hereby authorize representatives of this County ISSUANCE FEE '`O
co m to enter upon the above-mentioned property for inspection
purposes. 7
�� P ��5 J:f� y t /•�'
m INVESTIGATION FEE
TOTAL FEE/fJ
� Sgnalun!of Mpimnt a ApBN Gate / �J •
SEE REVERSE FOR EXPLANATORY LANGUAGE