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HomeMy Public PortalAbout9211 WEDGEWOOD ST_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN BUILD!*ADDRESS WORKERS COMPENSATION DECLARATION a// �J�����f,f�pb I hereby affirm that I have a certificate of consent to self insure, � .BUILDING ADDRESS � �.�� e 4-1�,�I or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3900.Lab.C.) CITYr _ , / IP c? 17 p u LOCALITY Policy No. Company SIZE OF LOTf� (� NO.OF SLDGS.NOW ON LOT 11Certified copy is hereby furnished. so g 1 NEAREST CRO ❑ Certified copy IS filed with the county building Inspection QCT BLOCK LOT NO. USE ZONE MAP NO. department. ASSESSOR MAP BOOK PAGE PARCEL Date Applicant �i7l� © / SPECIAL CONDITIONS / WITHIN l000 FT.OF SCHOOL? NO ' ADDRESS (This section need not be completed 11 the permit is for one hundred L t3���Q 3 DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) C� ZIPe 1 certify that in the performance of the work for which this permit j' 4-j � .� l ;;r, i0 if ,LO-9 is issued, I shall not employ any person in any manner So as to ARCHITECT OR ENGINEER TEL NO. become ee sub e�ct to the Mirka rs'107e11Gn Laws. STATISTICAL CLASSIR TION APT CONDO Date AppliADDRESS 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 TEL NO. SETBACK 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 LIC.NO. PL SIDE L•L I°8 LICENSED CONTRACTORS DECLARATION CITY / LIC.CLASS PL A a ; r0 I hereby affirm that I am licensed under provisions of Chapter 9 / SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ. .SIZE NO.OF STORES NOAFAMILIEMS TE Professions Code,and my license is in full force and effect. d NEW X BK PGFn DESCRIPTION OF WORK ADD ❑ VALUATION pop. t O f AL m License Number Lic.Cissa I /} /� o 0 ;--got Contractor Date ALTER ❑ `� ��- '- i °`�6� 13a I am exempt under Se REPAIR ❑ CHANGE I °LU B.&P.C.for this reason DEMOL ❑ LDMA P/C q Date: USE OF EXISTING BLDG. URM ❑ 00'101U-011101 1 IL}/� i�11 Signature APPLICANT(PRINT) TEL NO. LDMA Perm p Z 1J p+'` s C ❑ I, as owner of the property, or my employees with wages as O their sole compensation,will do the work and the structure is ADDRESS FINAL DATE Q 44 not intended or offered for sale (Section 70 , Business and Professions Code.) WILLTHEAPPLICANTOR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL J j p party em exclusively 9 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN ❑ 1, as owner of the ro y contractin with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project (Section 7044, YES❑ NO V5' a Business and Professions Code.) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. 1 hereby affirm that there is a construction lending agency for YES❑ Not& the performance of the Work for Which this permit Is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES / COUNTY CODE.TITLEZ CHAPTER 2.20 SECTIONS 2.20.100THROUGH 220.140 CONCERNING Lender's Name HAZARDOUS MATERIAL`S�FPO TI AND FOR OBTAINING A PERMIT FROM THE SCAOMD. Lenders Address ONNERORAGM o I certify that I have read this application and state that the above P.C.FEE PERMIT FEE / Information is correct. I agree to comply with all county ordinances and State laws relating to building construction,and ' r hereby authorize representatives of this County to enter upon ISSUANCE FEE the atZove entioned property for inspection purposes. C Q� INVESTIGATION FEE TOTAL FEE 8W9WIeMA ACM1WAp°M Ode `• SEE REVERSE FOR EXPLANATORY LANGUAGE