HomeMy Public PortalAbout5833 RENO AVE_Building__ `ti � ..� w . , .� LII �' BUILDING PERMIT
COUNTY OF LOS ANGELS BUILDING AND SAFETY
AWORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS 3 3
BUILDINSi ADDR
I hereby affirm that I have a certificate of consent to self insure, 3 $3 jr'Z.r914.0
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) CITY ZIP 4 LOCALITY
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CROSS ST s
Certified copy is filed with the county building Inspection TRACT BLOCK LOT NO.
USE ZONE MAP NO.
department. _
'2 AQ.
ASSESSOR MAP BOOK PAGE PARCEL
Data pplicant SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' /IRS Cd N IZ/I-ID 2 Q S lyd 79YES NO
ADDRESS
COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL?�
(This section need not be completed if the permit is for one hundred &S DISTRICT GROUP ITYPECONST.- FIRE ZONEC14kOCESSED BY
dollars($100)or less.) CITY ZIP
1 certify that in the performance of the work for which this permit I 5s
is Issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO. p O�
become subject to the Workers'Compensation Laws. �T(l yL-79 13 f./ rZ u 14 bC•R !.J 7- G7'7-g STATISTICAL CLASSIFICATION APT DO
Data Applicant ADDRESS CLASS No. '2 71 DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR TEL.NO.
p I C[HC12 ~ SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code,you must forthwith �`Al�-DriRS '4`7- 7
ADDRESS LIC.NO. FRONT
comply with such provisions or this permit shall be deemed revoked. �¢ 4 S n A 4/0 a w Y7 /9 3 P L
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS DE PIL
0
I hereby affirm that I am licensed under provisions of Chapter 9 lz a A DIA � s WER MAP c.-1
(commencing with Section 7000)of Division 3 of the Business and SQFr SIZE_ NO.OF STORES NO.OF FAMILIES NEW ❑ E}K PG
Professions Code,and my license is in full force and effect. ® v
License Number 41S 7/"'TX Lie.Class DESCRIPTION OF WORK ADD VALUATION W
Contrecto
riot i C�
��.-a =.-.fix �d -2- �� ALTER ❑ _ °�
❑ I am exempt under Sec. A�QCt^-rz A C— REPAIR ❑ $
B.BP.C.for this reason USE USE OF DEMO_ ❑
Date. OF EXISTING BLDG. URM ❑ ��j� ia
Signature APPLICANT(PRINT) TEL NO. LDMA Perm N 1
❑ I, as owner of the propert)4 or my employees with wages as 92 L 5 i o/d •A - sG Ho t L S - e"7 7 S Aa s
their sole compensation,will do the work and the structure is 11-
Professions
ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DATE 900- -,� -t
Professions Code.) it J! `�3('I7 '��"°!
WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL L
❑
I. as owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN a i TTEMS
Y 9 THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project (Section 7044, vEs❑ NO Oa TOTAL 432 16
Business and Professions Code.) LA/
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING s-; 2 o
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH �.1"ECK 4�°.r°�4
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST
CHANGE °l I-1
I hereby affirm that there is a construction lending agency for FOR GUIDELINES.YES El No�' 4111•TI1147G
the performance of the work for which this permit Is issued(Sec I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAGMD
3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES y /
COUNTY CODE,TITLE 2,CHAPTER 220 SECTIONS 220.100THR000H 220.140 CONCERNING 1►� I1-I]�I]t !I•/ 13/90
Lender's Name DOUSMATERIALSREPORTI AND FOR TAININGAPERMIT FROMTHESCAQMD.
a. Lender's Address '�` � 9867 1 AN 7:42
C MUM OR AGENT
0 1 certify that I have read this application and state that the above
Information is correct. I agree to comply with all county RC.FEE PERMIT FEE
41
ordinances and State laws relating to building construction,and
hereby authorize representatives of this County to enter upon ISSUANCE FEE �7
a J'
e�ia ova-mentioned property for inspection purposes. r,�, V
a~ � T ^-2-C76 INVESTIGATION FEE TOTAL FEE
lalpltl—WAPPIMda ft- DM
SEE REVERSE FOR EXPLANATORY LANGUAGE