The URL can be used to link to this page

Home My Public Portal About5221 SANTA ANITA AVE_Building__ APPLICATION FOR BUILDING PERMIT �I + !_ COUNTY OF LOS ANGELES BUILDING AND SAFETY _ VFORKER%COMPENSATION DECLARATION i FOR APPLICANT TO FILL IN BUILDI ADD /d'N BUILDIN�J1� ` I hereby affirm that I have a certificate of consent to self insure, // or a certificate of Workers'Compensation Insurance,or a certified I� copy thereof(Sec.3800 ab. CI owl 19 ` ZIP LOCALITY Policy No. Company SITS OF LOT G NO.OF LDGS.NOW ON LOT ❑ Certified copy is hereby fu ish NEAREST CROs ST Certified copy is filed wit a coun bu• g i I BL K LOT NO. e- dopa USEZONE MAP NO. Data r Applicant ✓ ASSESSOR MAP BOOK PAGE�� PARCEL �, SPECIAL CONDITIONS CERTIFICATE OF EXEM ION FROM ORKERS' L.N YES NO COMPENSATION INSURANC - WITHIN 7000 FT.OF SCHOOL? D RESS (This section n not be completed if the permit is for one hundred I DIsT�ICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or leg\) D Z — J i V I certify that in the p ormance of the work for which this permit f� t , � . I69 3 �J Is issued, I shall note?? loy any person in any manner so as to I NGINEER N become subject to the Wo re'Compensation Laws. _MgESTATISTICAL CLASSIFICATION APT CONDO Date Applican ADDRESS CLASS NO.n2 DWELL UNITS NOTICE TO APPLICANT.• If, a r making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemptiori, you should becom Subject to the Workers' I R NO _ SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labo ode,you must forthwith 1 ► T FRONT comply with such provisions or this permit all be deemed revoked. A �� L N 8 PL LICENSED CONTRACTORS DECLARATION c r � qnZ� LIC.C SIDE a 1 hereby affirm that I am licensed under provisions of Chapter 9 cx_ SEWER MAP (commencing with Section 700(1)of Division 3 of the Business and 1§fiff!g OF TORES J NO. FAMILIES o= Professions Code,a d lice is in full force and effect. NEW ❑ BK PG ® o License Nu Lib.Class DES ON OF �� ADD vAWATto n 6 COO � Contractor - Date i ALTER ❑ 3 ZREPAIR ❑ ❑ I am exempt under Sec. $ BAP.C. is on DEMOL ❑ LDMAP/C 0 SE ING BLDG. URM ❑ Signature T(PRINT) n LDMA Perm M Z � ❑ I,as owner of the property, or my emp with we as 4lGy9"+� r O their sole compensation,will do the wo and the structure is , ACT,?0 not Intended or offered for sale (Section 7044, Business and T2 "'O/`• SSBCarFINAL PATE /j Professions Code.) tIV1 �� 422.92 WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL ❑ I, as owner of the property; OR A MIXTURE Co AN NG A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN _ ITEMS p party, am exclusively contracting with THE AMOUNTS SPr FlED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FlNAL `J 1 i1€v licensed contractors to construct the project.(Section 7044, YES❑ No Business and Professions Code.) I TOTAL 4- 22-92 WILL THE INTENDED E OF THE eUILDING BY THE APPLICANT OR FUTURE BUILDING C STRUCTION LENDING AGENCY OCCUR4NTREQUIRE PERMIT FORCONSTRUCTION OR MODIFICATION FROM THE SOUTH I CHECK ryr G COAST AIR QUALITY ANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST 411 �•E 'fii FOR GUIDELINES. 1 hereby affirm at there is a construction lending agency for YES❑ NO CHANCE .00 the performance a work for which this permit Is Issued(Sec. I THE O IALS INFO TION GUIDE AND THE SCAQMD 3097,CIV.C.). ITn G CHECKLIST.I U D MY REQU ENTS UNDER THE LOS ANGELES Lenders NCERNING Name S MATERIALSC POR NGS FOOR D- NG A PERMIT FROM TNSTHROUGH 2M140 HE SCAQMD. Lenders Address E 0626 1 Alf 9:213 o' I certify that I have read-t is appli Ion and state that the above in ation IS CQ Ct. I agree to omply-with all County P.C.FEE PERMIT F o i nces and law tela to b Ing construction,and E' I h autho re}� nteti of this my to enter upon ISSUANCE FEE t le ove=me on fu p pe fo inspection � 6 n INyESTIGATION FEE TOTAL FEE • V S% App9mnarApenl Dub SEE REVERSE FOR EXPLANATORY LANGUAGE