HomeMy Public PortalAbout6026 PRIMROSE AVE_Building__ ryN/ APS ATJ �o�®in�G PERMIT
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NOUN OF LOS A FLIES,, BUILDING AND~2ArE�
IRKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN 4+! ti BUILDING ADDRE
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I hereby affirm that I have a certificate of consent to self insure, BUILDIP-ADDRESS
r OZ f p YYl(''tl�Ff� }/�
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) CITYLOCALITY-1Y ZIP
Policy No. Company e ` C P Y n u( / /
SIZE OF LOT y NO.OF BLDGS.NOW ON LOT �`��
13 Certified copy is hereby furnished. j e1..� ' NEAREST CROSS ST.
❑ Certified copynt. is filed with the county building inspection TRACT �� i BLOCK LOT NO. t
7 USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOKPAGE PARCEL SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER C(t f�/� TEL NO YES NO
COMPENSATION INSURANCE f L� (a i 1 WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred ADDRESs��� l��Q ���T
dollars($100)or less.)
�V C� DISTRICT GROUP TYPE CONST, RZONTE PROCESSED BY
I certify that in the performance of the work for which this permit CITY Fn �r1 —� ZIP_ ,� �( ele CC
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO 170 3
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION 333 3PT CONDI-0863 a 8th.
Date Applicant V1 ADDRESS CLASS NO. a/ DWELL UNITS I TTJlJQ
NOTICExemption, yo70 u s should become subject GMT.- If, after making this
heCertificatee s' `J CONTRACTOR TEL NO. SETT BACK YARD HWY REQUIRED ��L RET�QC FROM `EMX 3 81
Compensation provisions of the Labor Code, you must forthwith FRONT CHECK 186 oE4
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL
LICENSED CONTRACTORS DECLARATION Im SIDE 00
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.S E NO.OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. NEW BK PG ® 0000-0 001 5/28/96 CL
License Number Lie.Class DESCRIPTION OF WORK ADD ❑ VALUATION �� N Q
Contractor Date `' v. e �� ALTER ❑ S '-(; 6604 1 AMID 16 U
❑ cc
I am exempt under Sec.
REPAIR 11�� DEMOL 11U
88P.C.for this reason _ = "
Date: US EXISTING BLDG. URM ❑ LDMA P/C# 7�T a IL
H4 109
Signature Z
APPLICANT(PRINT) TEL!O. s 7 LDMA Perm#
I, as owner of the property, or my employees with wages as Z3303 540.79
their sole compensation, will do the work and the structure is ADDRESS
2�712 TI(Ar not intended or offered for sale (Section 7044, Business and i7 I(Ar A✓u 1Z0 &M&AV FINAL DATE Q 1 ITEMS
Professions code.) TOTAL 1540.79
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
❑ I, as Owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044, IFlE AMOUNTS SPECON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY CHECK 1540.79
Business and Professions Code.) YES❑ No
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPUCANT OR FUTURE BUILDING CHANGE .00
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❑ (� {�(�
the performance Of the Work for Which this permit Is Issued(Sec. (HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 0090--0001 10/25/955
1 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, �y��� 1 AM 7 a' 'L
a TITLE 2.CHAPTER 2 20 SECTIONS 2.20.100 THROUGH 2 20 140 CONCERNING HAZARDOUS
Lender's Name MATERIALS REPORTING AND F ROB ININ pERM1T FROM THE SCAOMD.
0 Lender's Address
0 OWNER OR AGENT
0 I certify that I have read this application and state under penalty /���. PERMIT FEE �i
of perjury that the above information is correct.I agree to comply P.C.FEE /� ro
$ with all county ordinances and State laws relating to building
construction, and hereby authorize representatives of this County ISSUANCE FEE a,y
m to enter upon the above-mentioned property for inspection purposes.
Wy�-!/-Y f01/ �j �� INVESTIGATION FEE TOTAL FEV,? / d+ 14
' S"uw of hd� « m am z' Ls i O
SEE REVERSE FOR EXPLANATORY LANGUAGE