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HomeMy Public PortalAbout9027 JAYLEE DR_Building_7/7/1993_bd and bathroom, ldry room APPUCAMON FOR BULONG PERMIT COUNTY OF LOS ANGELFES• << BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN '7 BUILDING ADDRES®^ V/ 45 Ae I hereby affirm that 1'have a certificate of consent to self insure, BUILDING ADDRES (1_ �[. or a certificate of Workers' Compensation Insurance,or a certified ����I 54AI �� /77.E copy thereof(Sec.3800,Lab.C.) CITy�_ //�j� j1 J ZIP' 91 7 7� LOCALITY Policy No. Company SIZE OF LOT - 'NO.OF BLDGS.NOW ON LOT ❑ Certified Copy is hereby furnished - NEAREST CROSS ST , / - ❑ Certified copy is filed with the County building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. . Applicant 'ASSES�t MAPBOOK PAGE PARC Date A L /n Pp fffi 3 © SPECIAL CONDITIONS OWNER /' _ TEL WITHIN 1000 FT.OF SCHOOL? YES NO COMPENSATION INSURANCE: I/A E (This section need not be completed if the permit is foADDRESr one hundred �oa '7 DISTRICT GROUP TYPE CONST: FIRE ZONE PROCESSED BY ' dollars($100)or less.) ! I certify that in the performance of the work for which this permit GICT'' ZIP C�77� ©� is issued, I shall not employ any person in any manner so as to / become subject to the Workers'Com ensation Laws. ARCHITECT OR ENGINEER TEL NO. _ P STATISTICAL CLA SIFjCATION APT CO O 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 FRONT comply with such provisions or.this permit sha11'be deemed revoked. ADDRESS LIC.NO. PL SIDE LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS P.L I hereby affirm that I am, licensed underprovisions of,Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3'of the Business and S .FT.SIZE NO.OF STORIES NO.OF AMILIES Professions Code,and my license is in full force.and effect. NEW El BK PG D a DESCRIPTION WORK •• ADD VALUATION Q License Number Lic.Class �f �"(Tv $ G 0 U Contractor "` Date � �. ALTER ❑ cc L !2 P-o 6-- 0 ❑ I am exempt under Sec. REPAIR ❑ $ B.&P.C.:for this reason �d DEMOL ❑ V LOMA P/C#- W -Date: UQL,&EXISTING DG. - URM ❑ Signature - - APPLICANT(PRINT). - TEL NO. _ LDMA Perm# ' { - - z Z = f I'e . I, as owner of.the property, or my employees with wages as a their sole compensation, will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and FINAL DATE. Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL -9 + OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ' I J ❑ 1, en owner Of the. property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY .•_1�_ �, .> y(_, I licensed contractors to construct the project (Section,7044, YES El No 11Business and Professions Code.)' -i-- ._ " �_j WILL THE INTENDED USE OF THE BUIDLING.BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTHy� CONSTRUCTION LENDING AGENCY COAST AIR.QUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR - .. . 1, �? TEli=7 ' GUIDELINES. 1 33 .-g... . .. I hereby affirm that there is a construction lending agency for YES EJ NO❑ i ITL� 5'ra9- o 5 1 w the performance of the work for which this permit Is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING �jj[ ({.f 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, - :•ilGi.•K Ce;j•F e C N TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS 3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE_SCAQMD. .^� ?_•i'h�t3L 'S tl l o Lender's Address O. OWNER OR AGENT o I certify that I have read this application and state under penalty o P.C.FEE PERMIT.FEIS of perjury that the above information is correct.I agree to comply � ' `%C f t•. - �„ 11_Ea if.i—�I13[?�, i`.j o with all county ordinances.and State laws relating to building W construction, and hereby authorize representatives of this County ISSUANCE FEE �� �� #i�: Vii°( n;ii " t enter upon thea ove-mentioned property for ins ection p In INVESTIGATION FEE' TOTAL FEE /r SigriaNre of ADDIi t or Agent ate SEE REVERSE FOR.EXPLANATORY LANGUAGE