HomeMy Public PortalAbout6163 RENO AVE_Building__ Y -� nr' " . - APPLICATION FORBUIiLDING PERMIT
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*� COUNTY dF LOS,ANGELES !�I I� BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS _/1
BUILD G AD ESS
I hereby affirm that I have a certificate of consent to self insure, D 4
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof,(S .3 1a C� ,/ CIT_ ZIP
/ d� `Y' LOCALITY
Policy Nd�' mpa y S E OF NO OF BLDGS.NO ON LOT
❑ Certified copy is hereby furnished. �� �•p O lj� O NEAREST CROSS ST
❑ Certified copy is filed with the county building Inspections TRACT K LOT NO
department. USE ZONE MAP NO.
Date ��� Applicant Ute. iE. Iry P-a�� ASSESSOR MAP OK PAGE PAR�jEL ~Q
3� Q� U SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OW TEL NO., V 7
COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? YES NO
ADD S
(This section need not be completed if the permit is for one hundredSENO 0!' DISTRICT GROUP TYPE CONST FIRE ZONEZROCESSED 13Y
dollars($100)or less.) ✓v
CIT 1 ZIP ��
I certify that in the performance of the work for which this permit fJ 2
is issued, I shall not employ any person in any manner so as to pf !•(. ,J
ARCHITW R EbIG ER y, ELN L�
become subject to the Workers Compensation Laws. '( gp' /y�/ y/^ /1�r STATISTICAL CLASSIFICATION �C / APT CONDO
Date Applicant �//,y� VW U /I� CLASS NO. DWELL UNITS _/
NOTICE TO APPLICANT.• If, after making this Certificate Of ✓lam e ` 113 REOUIRED TOTAL SETBACK FROM EXIST
Exemption, you Should become subject to the Workers' NT CTOR _ I I TEL O SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith l At G & a A D— 1 FRONT �?
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO PL
iii tf f Y a a
/ 7 7 7 1 �r SIDE
LICENSED CONTRACTORS DECLARATION v J
�1 CITY /7 LIC CLASS P L 1?Il? Mfg j�ry� C
I hereby affirm that I am licensed underprovisions of Chapter 9 `} SEWER MAP y
(commencing with Section 7000)of Division 3 of the Business anc� `�t SO FT $IZ NO.OF STORIES NO F FAMILIES NEW BK PG I ITEMS 12
C
Professions Code,and my license is in full force and effect. J�.►\V Tp i a L
DESrRIPTION OF WO K VALUATION , I O 1 AL 1 L=56 l'"
License Number Z Lic.Class / ADD ❑
Contractor c 4esy,5/. Date 7 e ALTER 11 $ �� CHECK 16910 56 a
_ ,,�•
❑ 1 am exempt under Sec. REPAIR ❑ $ r7� 7 �_ CHANGE .002
B.AP.C.for this reason DEMOL ❑ 00l7
Date: LDMA P/C p +�r�+, r,
`M`1 US - F EXISTING BLDG. URM ❑ �dl.Iu�—��U 1 ❑�r€i�'I70
Signature \ APPLI N7 PFV T) TEL NO ( LDMA Perm t I�.;�A¢5.4L 1 r 11 5.'20
❑ I, as owner of the property, or my employees with wages Z -+ O
their sole compensation, will do the work and the structure is A E O 333, 138 o f 1l
not intended or offered for sale (Section 7044, Business and 0 FINAL DATE F 1
Q
Professions Code.) O
LL TAE APPLICANT OR FIJTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MA ER 12— � � F1-j �
❑ 1, as owner of the property, am exclusively contracting WithA MIXTURE CONTAINNG A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q AC(T.0
1 R 4
'AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE
licensed contractors to construct the project (Section 7044, FINAL BY > „�� �,#I�,
YES❑ NO 1 3303 ,.s_Rnl -
eusiness and Professions Code.) \
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING ITEMS
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM tHE SOUTH 1 1 f 11
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR TOTAL 2343.51
GUIDELINES
I hereby affirm that there is a construction lending agency for s❑. NO❑ Ul/
the performance of the work for which this permit is issued(Sec. FE�Eti j'�g,r11.
IIVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ,
3097,Civ.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. 1 f'f"(
TITLE 2.CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20.140 CONCERNING HAZARDOUS CHANGE �}'-
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD
LendLlhave
DATER OR AGENT
3 I cere read this applic Ion and state under penalty 0000--0001 7/12/9G. of peabove inf rmatio iS Correct.I agree tO comply P.C.FEE / PERMIT FEEr,:with rdinances(9and tate laws relating to building7L�6 1 Af ;• [;m consthereby author' a representatives of this County ' 'JO ISSUANCE FEEto en bove m, do ed property for inspection purpo s.d ! 7� 1` INVESTIGATION FEE TOTAL FEE at
,wI a ASI v Apau D.va O� d
SEE REVERSE FOR EXPLANATORY LANGUAGE