HomeMy Public PortalAbout10551 DANBURY ST_Building_6/30/1992_roof tile .COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
eUILDI GADDRESB u � �,/
1 hereby affirm that I have a certificate of consent to self insure, S I
or a certificate of Workers'Compensation Insurance,or a certified CI J ZIP
copy the (Sec(Sec ,3.g�ppr Lab.C.)
Policy Novl�`'' IZ a�LCompany ^to f'L L^' _ LOCALITY
SIZE OF LO NO.OF BLOCS.NOW ON LOT
❑ ST'
copy is hereby furnished. NEAREST CROSS S
,,E Certified copy is filed with ih my building inspection TRACT BLOCK LOT NO.
USEZONE MAP NO.
tlep en[.
ASSESSOR MAP BOOK PAGE PARCEL
Data 3� Applicant SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTIO ROM WORKERS' OWNER D TEL.NO. VES NO
COMPENSATION INSURANCE ZK 7Z WITHIN 10M FT OF SCHOOL?
ADDfl 5
(This section need not be completed if the permit is for one hundred J DISTRICT GflOUP TYPE CONST.' FIRE 20NEPROCESSED BV
dollars($100)or less.) CITY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner s0 as to
ARCHITECT OR ENGINEER TEL.NO. ��� •` " L��-�
become subject t0 the Workers'Compensation Laws. STATISTICAL CL�AS//SIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. 1;2 DWELL
DWELL UNITS
NOTICE TO APPLICANT: If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, , CONTRALTO TEL.NO.
p you provisions
become Lab subject, t0 the Workers' SETBACK YARD HWV PROP LINE WIDTH
Compensation provisions of the Labor Code,,you must forthwith 77 O FRONT
comply with such provisions or this permit shall be deemed revoked. PL
ADDRESS yy.. LIC.Noq.
HG DG/�s /.� SIDE y
LICENSED CONTRACTORS DECLARATION CITY 6 LIC.CLASS 9 P L
I hereby affirm that I am licensed under provisions of Chapter 9 A 2y GSEWER MAP S
(commencing with Section 7000)Of Division 3 of the Business and SIFT S E NO.OF STORES NO.OF FAMILIES C
Professions Code,and my license is in full force and effect. O� NEW ❑ BK PG D CD
License Number S'b3 Lia Class G3 DESCRIPTION WORK T �p ADD ❑ VALUATION
Contractor 4 L- Date 3 0 w V rti �--+ ALTER ❑ $ ii -- - Z
d C>41a REPAIR
1:11 am.exempt under Sec. C O r�G,�].. $
BARC.for this reason J T I / rD C LDMA P/C p
Date: USE OF EXISTI CDG. URM ❑31
Signature_ APPLI (PRINT) TEL.NO¢ n �/ CDMA PzmIM _.^_i! .LJJz l•`_�
❑ I, as owner of the property, or my employees with wages as VL�- 7 17 / ( � - Q
their Sole compensation, will d0 the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FtRAL DATE
Professions Code.)
WRLTHE APPLICANTOR FNG A HAZARDOUS
US MATERIAL QUAL TO
MATERIAL /'��I O li'•jJ 1=i' '..
❑ I, as owner of the property, ORA M TEHAZARDOUS MATERIAL EQUAL TO OR GREATER THAN J il[.i.•at E-1 ;`-'
p p rty, am exclusively contracting With TNEAMWNTS SP IED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BYL";i
licensed contractors to construct the project.(Section 7044, 1 /Q„p„� / _, i _; €_i
Business and Professions Code.) YEs❑ No /Y r'<Ylu
WILL THE RE X.E.USE MI THE BUILDING BY THE AP MODIFICATION
FURORE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR DUALITY MANAGEMENT DISTRICT(a OMDI SEE PERMITTING CHECKLIST
FOR GUIDELINES. _ ,,•.j y,)_.; ?,,;,
I hereby affirm that there is a construction lending agency for YES❑ . No ,,ty 3 f
the performance of the work for which t ;s permit is issuetl(Sec. -- r u
3OB7,CIV.C.\. I HAVE READAT2.
OUS MATERI 5 FORMPTION GUIDE AND THE SLAOMD
1 PERMITTINGNo- TAN EOUIREMENTS UNDER THE LOS ANGELES
COUNTY COPTER2X ONS2.M1.1NTHR000H2.ffi1b CONCERNING
Lendels Name HAZARDOUORT NO FOR OBTAINING A PERMIT MOM THESCAOMD.
Lender's Address
Q owNrAaR
o' I certify that I have read this application and state that the above P.C. EE PERMIT FEE
information is correct. I agree to comply with all county . /LO
ordinances and State laws relating to building construction,and cJ j?7
hereby authorize mpr ,Bntalives of This County to enter upon ISSUANCE FEE
the above-mentione party for inspection pu `o7P
Ao.a
o�n i INVESTIGATION FEE TOTAL FEE 1. O .
SEE REVERSE FOR EXPLANATORY LANGUAGE