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HomeMy Public PortalAbout5730 RIO HONDO AVE_Building__ APPLICATION. FOR, BUILDING PERMIT COUNTY OF LOS ANGELES 1!( BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN fB�UILD�IINNG ADDRESS 7-90 �� BUILDING DDRESS I hereby affirm that I have a certificate of consent to self insure, �� •�v <<7 v �.� 0 ��j T or a certificate of Workers Compensation Insurance,or a certified CITY K ZIP e&� `–` ` copy thereof(Sees 80 .r.) /�1 g� LOCALITY Policy N0. fa e Company SIZE OF LOT CJ NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. - ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. J� department. �i 1 /1 rA USE ZONE MAP NO. Date ���� ` *pplicant 'wy'1I I vV 4(I ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. YES NO COMPENSATION INSURANCE ^`AL& O 285-?s WITHIN 1000 FT.OF SCHOOL? (This section need not be completed if the permit is for one hundred ADDRg; 2 ��O s J DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) CITY ZIP I certify that in the performance of the work for which this permit e 1'7 C. _2 Ly is issued, I shall not employ any person in any manner so as to ARCHITECT O ENGINEER TEL NO. J become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. 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 T�EL NO. aQ SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith O 11 ySks.g�0v FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS] ��16 �� IC.NO����e PL SIDE LICENSED CONTRACTORS DECLARATION CIT /� /J.4 * LIC.CLAS —:—L I hereby affirm that I am licensed underprovisions of Chapter 9 `a �� - SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE ; NO.OF STORIES I NO.OF FAMILIES NEW ❑ BK PG Professions Code,and my Iic nse is in full force and effect. `S , a License Number 1 — Lic.Class DES R TION O WORK ADD ❑ VALUATION o,� C Contractor Date I 2d "�[S t/ ALTER ❑ $ ` �dv� 3 a 40 'r4ZOAIT 132W,V4 REPAIR A ACCT°v H ❑ 1 am a mpt under Sec. �y ry 4nn B.BP.C.for this reason S DEMOL ❑ LDMA P/C# 3`03 V°•JU U Date: USE OF EXISTING BLDG. URM ❑ 1 V Signature APPLICANT(PRINT) TEL NO. LDMA Perm# ACCT.� ❑ I, as owner of the property, or my employees with wages as Z - -+ their sole compensation, will do the work and the structure is ADDRESS O 3.3O3 1`r°8°85 not intended or offered for sale (Section 7044, Business and FINAL DATE G 2 ITEMS Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL '2�r OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ I, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY > TCTAL � o licensed contractors to construct the project (Section 7044, YES❑ NO❑ CHECK 209.35 Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CHAhIGE .00 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT ISCAQMD)SEE PERMITTING CHECKUST FOR 394�6 Am S ©`L GUIDEUNES. J'I^Y Li 1�7�* I hereby affirm that there is a construction lending agency for YES 11 NO El ��}}��yy(�yyqq a the performance Of the work for Which this permit is Issued(Sec. IHAVEREAD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMDPERNIrTING 0000-�} 01 11/21/95 a 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, a TITLE 2,CHAPTER 2 20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS Z/.fy(7 i GH L o i Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. +7400 1 r"H a 22 0 Lender's Address MVNER CR AUNT 0 0 I certify that I have read this application and state under penalty 0of perjury that the above information is correct.I agree to comply P.C.FEE t , 0,-0PERMIT FEE N with all county ordinances and State laws relating to building construction, and hereby authorize representatives of this County ISSUANCE FEE co to enter upo the above-mentioned property for inspection purpos s. i o_r INVESTIGATION FEE TOTAL FEE A of qv tlnl a A" SEE REVERSE FOR EXPLANATORY LANGUAGE i WC 4ERS'COMPENSATION DECLARATION 11:I sur ,o affirm that I have r certificate of cornsent to self ■ I�L I T I N FOR �U I L®INC PERMIT CT, insure, or a certificate of Workers'Con�ensation Insurance, or a certified copy thereof(See. 3800,Ibb. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. BUILDING 3D ❑ Certified copy is filed with the county building inspec- BUILDING FOR APPLICANT TO FILL IN ADDRESS tion department. ADDRESS 1 " 6).FVA" Date Applicant CITY IJNO. , ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT /� NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one Q� ASSESSOR hundred dollars($100)or less.) TRACT BLOCK LOT NO. ((fly MAP BOOK PAGE PARCEL r • T L. USE NE MAP / �y I certify that in the performance of the work for which this OWNER .L O. NO. oG } permit is issued, I shall not employ any person in any manner - /30� iO �'p CONDITIONS so as to become subject to the Workers'Compensation ws ADDRESS Date If—15 Applicant A 1 CITY�� p�, C: ZIP 178'0 09 ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESS D BY NOTICE TO APPLICANT: If, after ma g this Certificate of ENGINEER y..d✓s t// �+Q NO. Exemption, you should become subject to the Workers' CONST ZONE Compensatin provisions of the Labor Code, you must forth- ADDRESS s0� a @� with comply with such provisions or this permit shall be afD deemed revoked. /t/ �U�D TELNO C STATISTICAL CLASSIN TION APT. CO O. g CONTRACTOR v v J LICENSED CONTRACTORS DECLARATION ��// LIC, CLASS NO. DWELL: UNITS — 9 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS .30 ?io NOv NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP ` Professions Code,and my license is in full force and effect. , CITY CLASS BJ PG VALIDATION SQ.FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE- STORIES FAMILIES ONE ' o VALUATION Contractor Date DESCRIPTION OF WORK Q A3 NEW ❑ $ � , I/ ADD U (J ❑ I atyt exempt under Sec. . 5 ba ALTER ❑ c B.&P.C. for this reason U51.1�-t ex,511ri l ( V( k REPAIR ❑' $E OF 1 0 6 4 4, Date' EXISTING BLDG. S/ DEMOL ❑'.. p (� r. 2 Signature L-(fir APPLICANT (PRINT) j .NOL��5 FINAL -DOWNER-BUILDER DECLARATION _ DATE Z���' I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS 3 1 /0 }�/I✓'.00 �v - FIN C' r 1611— Pro essions Code): PRESENT QAB BUILDING 3 O I`/O Io/VQ I, as owner of the property, or my employees with �. ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). -'MOVING TEL. ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). _o REQUIRED TOTAL SETBACK FROM a e e$ CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH a 2 9 a 5 1 hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. -29a505 (Sec. 3097, Civ. C.). SIDE P.L. 051 5 -87 i Lender's Name [� ` ! LDMA Ref. # I P.C.Fee$ C) Permit Fee L� Lender's Address I certify that I have read this application and state that theIssuance Fee LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee L� ordinances and State laws relating to building construction, Total Fee / S LAMA Perm.# i and hereby authorize representatives of-his County to enter upon thear-- a-me MNAIn-r7 ection purposes. _� SEE REVERSE FOR EXPLANATORY LANGUAGE n tura yT�or nt Date v0 .. Lp/LL�_ _ /l.,slst .