HomeMy Public PortalAbout5033 SANTA ANITA AVE_Building__ i
APPLICATION FOR BUILDING PERMIT �1
COUNTY OF LOS ANGELES , BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION I FOR APPLICANT TO FILL IN ELOCA
DRESS
I hereby affirm that I have a certificate of consent to self Insure, BUILDING ADDRESS
or a certificate of Workers'Compensation Insurance,or a certified CITYfin zIP 4 I►n-
copy thereof(Sec.380,Lab.C.) i Policy No. Company l,L:,SIZE OF LO NO.OF BLDGS.NOW ON LOT
Certified copy is hereby fumished. OSS ST.
❑ Certified copy is flied with the county building Inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
ASSESSOR MAP BOOK PAGE PARCEL
Dam Applicant I I SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' R L NO. _ YES NO
COMPENSATION INSURANCE AD Ess WITHIN 1000 FT OF SCHOOL?
(This section need not be completed if the permit is for one hundred 10 IQ D)))I...ST...RICT G OUP TYPEECCOfN�ST.' FIRE ZONE ROC BY
dollars($hat or less.) CITY 1. q1606 ZIP L. V
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I certify that in the performance of the work for which this permit [Q p 6 J, 3 I (��OJ�
IS issued, I shall not employ any person in any manner so as to ARCHIT CT R (NEER TEL.NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant D r CLASS NO. DWELL UNITS
NOTICE TO APPLICANT. If, after making•this Certificate of 1 a REQUIRED TOTAL SETBACK FROM DIST
Exemption, you should become subject to the Workers' CO CTOR TEL.NO. SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code,you must forthwith
ADDRESS LIC.NO. FRONT
comply with such provisions or this permit shall be deemed revoked. PL
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS SIDE 23
PL p
1 hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP WA,I e a' v
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORES NO.OF FAMILIES �
Professions Code,and my license is in full force and effect. rg NEW BK PG ® �,� � �_s o rzL
2.
License Number Lic.Class +ESCRIPTION OF WORK 4�D 0 �� ue�0�ADD VA5 1 ITE € a
Contractor Date �) CO)
1 L ALTER ❑ TOTAL AL 5�1®4-
"� REPAIR ❑
❑ I am exempt under Sec. $ 59 , ( CHECK 521.48
B.&P.C.for this reason DEMOL ❑ LDMA P/C V CHANGE .00
Date. USE OF EXISTING BLDG. URM ❑
Signature Z 0000-0001 1IL/90
g b AP NT(PRI TEL NO. 7 LDMA Perm a O
❑ I, as owner of the property, or my employees with wages as M y
their sole compensation,will do the work and the structure is AD KESS FIN DATE F 01013` 1 AM t`:0y
not intended or offered for sale (Section 7044, Business and � q� �•�, (O•
Professions Code.) WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL /
❑ 1, as owner of the property, am exclusive) contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN
Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL B
licensed contractors to construct the project.(Section 7044, YES❑ NO❑
Business and Professions Code.) ACCT.Is
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING �, •r
OCCUPANT REQUIREA PERMIT FORCONSTRUCTION OR MODIFICATION FROM THE SOUTH I
CONSTRUCTION LENDING AGENCY f1 COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST 107 632.69
V FORGUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ NO❑ 1 Eli
the performance Of the work for which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD . •• rh•
3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES t x'13 1 R{ 6:32-4:59
COUNTY CODE,TITLE2,CHAPTER ZMSECTIONS 2.20.100THROUGH 2.2MI40 CONCERNING - _ .�i
Lender's Name �I HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. 0 ��'• - CHECK �-,J�S 69
Lenders Address �tl s 00
I�O,AGen CHANGE 1
o• I certify that I have read this application and state that the above P.C.FEE C PERMIT FEE 1�
information is correct. 1 agree to comply with all county `J
ordinances and State laws relating to building construction,and s J
hereby authorize representatives of this County to enter upon ISSUANCE FEE 1` D j�O—�i0 i I rk/ 41?r%I
the above-mentioned for insp i p � !
m r INVESTIGATION FEE TOTAL FEE 1 0510 ASE 8:16
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