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HomeMy Public PortalAbout9015 ACASO DR_Building_4/30/1996_reroof over existing roof N FOR BUILDING PERMIT . I. ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION O FILL IN BUILD G ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING or a certificate of Workers' Compensation Insurance,or a certified © Jr _ �C copy thereof(Sec.3800,Lab.C.) CITY LC �( ZIPdr��O LOCALITY _ Policy No PICT �� ^9'�Company ST�� Ieyy� SIZE OF LCT NO.OF BLDG/S.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. 01Certified copy is filed with the unty I Ing inspection TRACT BLOCK LOT NO. department. , USE"ZONE MAP NO. Date!/-30-554 Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER� !�^s TEL NO. COMPENSATION INSURANCE � v l��G�� WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS �.. f �MT�o ��•� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) I is CITY ZIP certify that the performance of the work for which this permit �A p�A issued, I shall not employ any person i any manner so as to ARCHITECT OR ENGINEER TEL NO. become subject t0 the Workers'Compensation ion Laws. - STATISTICAL CLASSIFICATION PAPT 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 TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith C-A 666- DO rc-16 `029/ -,S--70P FRONT Comply with SUCK provisions Or this permit Shall be deemed revoked. ADDRESS LIC.NO.3 �1 p L }v27 N L( ��/� s� SIDE LICENSED CONTRACTORS DECLARATION Q CITY LIC.CLASS PL V I hereby affirm that I am licensed underprovisions of Chapter 9 T—�? PC(_ SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO.FT.'SIZE NO.OF STORIES NO.OF FAMILIES 0� Professions Code,and my license is in full force and effect. NEW ❑ BK PG O License Number 161 S�/ Lie.Class G 3/ DESCRIPTION OF WORK ADD ❑ VALUATION A Od , U LLI Contractor � L� /Zoory�' Date �/30 �/` uy(r-tL �� �L�6 ��� ALTER ❑ $ ! S� n- N ❑ 1 am exempt under Sec. REPAIR ❑ $ Z BAP.C.for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ {-7 Signature :330 3 .01 APPLICANT(PRINT) TEL NO. LDMA Perm# ❑ I, as owner of the property, or my employees with wages as Z ER-COR their sole compensation, will do the work and the structure is ADDRESS O � y not intended or offered for sale (Section 7044, Business and FINAL DATE Q 5 0-.J —.01 Professions Code.) , G 1 WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A'HAZARDOUS MATERIAL -C. � .J OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE " I, as owner of the property, am exclusively contracting with Q AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? licensed contractors to construct the project (Section"7044, FINAL BY > ACCT. Business and Professions Code.) YES❑ No❑ WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING 3303 108090 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR 4 ITEMS tE 11 isiL GUIDEUNES l 3. I hereby affirm that there is a construction lending agency for VES❑ - NOE) i l � the Of the WOfk for which this permit IS ISSUed(See. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 8 - 90 30977,,Civ. C.)C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, CHECK 108.90 v) TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. CHANGE .00 Lender's Address cc OWNER OR AGENT 3 1 certify that I have read this application and state under penalty P.C.FEE PERMIT FEE { /_`} 0 of perjury that the above information is correct.I agree to comply �// / 01000-0001 f gU Ji <n with all county ordinances and State laws relating to building i /V m construction, and�Brebuthorize representatives of this County ISSUANCE FEE �Di 1 1 ' c a06 to enter po ntioned property for inspection purposes. CY To L INVESTIGATION FEE TOTAL FEE rotu ,cant Agen, Date SEE REVERSE FOR EXPLANATORY LANGUAGE