HomeMy Public PortalAbout5014 RYLAND AVE_Building__ APPLICATI.ON FOR BUIL®INC PERMIT
' COUNTY OF LOS ANGELES �lgiLt7 6 I;ND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN
7EIYADDRES
BUI N DR 3S1 hereby affirm that I have a certificate of consent to self Insure,
or a certificate of Workers'Compensation Insurance,or a certifiedcopy thereof(Sec.3800,Lab.C.) C�ITY ^, �./�. ZIP
Policy No. CompanyGCC /
SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. g94o NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT - BLOCK LOT NO.2 l
department. I USE ONE MAP NO. _
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER 01'El-NO.
COMPENSATION INSURANCE 1 _ WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred i ADR 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 •-7-+-� / ZI ,Of
is issued, I shall not employ any person in any manner so.as to NCHrr. OR ENGINEER TEL NO.become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant S CLASS NO.a DWELL UNITS
NOTICE TO APPLICANT If, after making •this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of-the'Labor Code, you must forthwith FRONT �
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIG.-NO. P L i73
LICENSED CONTRACTORS DECLARATION SIDE ' as
4`� i cITY Llc.cLAss P L
I hereby affirm that I am licensed underprovislons of Chapter 9 V i SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and I SO SIZE - NO.OF R }
Professions Code,and my license is in full force and effect. j� /` W 111❑000 BK PG 1 ITEMS p_
License Number LIC.Class. DESCRIPTION OF WORK pp VALUATION TOTAL o V
Contractor Date ! -- O AL R ❑ $ CHECK 671°94 0M
REPAIR ❑ 0
❑ I am exempt under Sec. fir,—/ D D CHANGE °00
BAP.C.for this reason DEMOL ❑ !�
Date: g�USEISTING BLDG. p�' SF• / �jr URM ❑ LDMAP/C n • �ee aSignature (PRIATT) CTEL NO. LDMA Perm# zI, as owner of the property, or my employees with wagesas �G Z ;ACCTeatheir sole compensation, will do the work and the structure is C
not intended or offered for sale (Section 7044, Business and 14zFINAL DATE G 3303 1063°85
rofessions Code.) WILL THE APPLICANT OR FUTURE BUILDING OC PANT HANDLE A HIZARDOUS MATERIAL1.
s ,� J 1 ITEI'IS
as owner of the property, am eXclusivel contractingWith OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
/ v y y icensed contractors to construct the,project (Section 7044, OUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY • > TOTAL 1063.85
lYES 1:1 NO 11 ,
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING 5 .'CHECK 1063.85
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION.OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SGAOMD)SEE PERMITTING CHECKUST.FOR
GUIDEUNES I 4HANGE °00
I hereby affirm that there is a construction lending.agency for YES❑ No❑ ; 1' r
a the performance of the work for which this permit is issued(Sec.
O� I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING , 9/28/95
�` p
3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, 1 00000001 71fJ rp
r TITLE 2,CHAPTER 2.20 SECTIONS.2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS _ 000V U �7
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
Lender's Address 2546 1 PM 4 0.48
O OWWER OR AGENT
o I certify that I have read this application and state under penalty
4 of perjury that the.above information is correct.I agree to comply P.C.FEE r PERMIT FEE, �a
of with all county ordinances and State laws relating to building
construction, and hereby authorize representatives of this County 'ISSUANCE FEE
m e n the abo -ment' e ro rt�for inspec'on purposes.
m INVESTIGATION FEE TOTAL FEE
r` .sa.". APP1,nt'or APBM Dale ,
SEE REVERSE FOR EXPLANATORY LANGUAGE
I
DwARTmmT cg.S ubim AND SAFETY APPLEaTION FOR PF.Bbfft
COUNTr OF LOS ANGEM BUILDING
WM. J. F=. CHIEF ENGINEER
FOR JLPPLICILIIT TO FmL M FOR OFFICE DSS ORLT
OUlLa1N0 DISTRICT NO. PLAN CK. NO. PERMIT NOt
ADDRESS /Y `� 31�ST3�Z/ sa r3 r->y
LOCALITY RECKIVKO BY DATE OF AP L DATE ISSUED
� t
NEAREST .J �,�_ B
CROSS !'
fTa t- .% •' IN � L//y
ADDRESS
OWNER
MAIL LOCALITY G
ADDRESS rc. C.�w�' B 7 NEAREST
FC ST.
CITY prC/Y� �� 4't��* NO. FIRE NO.O PE UP
ARCHITECT OR TEL ZONK PLANf�
ENGINEER ' NO. BLDG. ORD. NO.
�•_ SETBACK LINK 9
ADDRESS APPROVED
TKL EY DATE •
t CONTRACTOR Ir NO• USE APPROVED
MON40004 BY DATE
ADDRESS � HOUSE NUMBERING
AL
DESCL RIPPTION IAT NO. /� BLACK MAP NUMBEQFIRLD CHECK EY
TRACTNO. ASSIGNED BY ATE
NO.OR ELD=.
SIZE OR LOT NOW ON LOT ,r—A,7,'j—.o_comm
n !'
CIE
MISTING ELDG. O FANIUM � �L V
DT�TIOTf OF WOR[
0
NEW ALT�LAT[ON ADDITION
L� O
REPAIR DEMOLITION I � E
SIZE D ROOMS STORIES
/ 1'
I Row
COVER NO _ - COVERING Ss- ': 1 i• C d a/ E O�/(a��
USE BTR • t
Eof
'� -r..�c•6 -^A
JLPBROVJLw '
INSPECTOR'S SIGNATURE DATE
1 HERS■Y ACKNOWLEDGE THAT 1 HAVE READ THIS AP- FOUNDATION.LOCATION
PLICATION AND STATE THAT THE INFORMATION GIVEN IS FORMS, MATERIALS
CORRECT.
1 AGREE TO COMPLY WITH THE CORRECTIONS LJS773D ' FRAME.FIRE STOPS. [�' 7-)14
O
HERSON AND WITH ALL COUNTY ORDINANCES AND STATE BRACING, BOLTS / ) "J
LAWS REGULATING BUILDI CONSTRUCTION. "i0 FURNACE:LOCATION.
SIGNATURE OF 1, �' •N� C, �y .�,L� GAS VENT, DUCTS
LATH. INT.
ADORXIMI— le IT 17
LATH, IDIT. -
AUTHORIZED AGT.
q�• PLASTER. INT.
' 7swYaA•Dens fo•w � P.C � C L .�
® 9 FEE. PLASTER. MIT.
VALUATION FEE �Z 14 b� FINAL W k4 H -51012