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HomeMy Public PortalAbout9192 JAYLEE DR_Building_12/7/1995_new roof APPLICATION FOR BUILDING PERMIT COUNTY OF'LOS ANGELES BUILDING AND SAFETY WORKERS COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, Bl111-2 ADDDRESS�� 9A or a certificate of Workers' Compensation Insurance,or a certified LL�� copy thereof(Sec.3800,Lab.C.) CITY ZIP . C/1 /- LOCALITY Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT / G ❑ 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. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' ow ERn,I A �U�4 �Sa YES No COMPENSATION INSURANCE � ` WITHIN 1000 FT.OF SCHOOL? This section need not be completed if the permit is for one hu d ed AD91HSS DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) (.certify that in the performance of the work for which this permit CI AA ��. ZIP 4 7� is issued, I shall not employ any person in any manner so as to '►t become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO. . P STATISTICAL CLARIFICATION APT 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 w , TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith G�ir� FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS - LIC.NO. P L LICENSED CONTRACTORS DECLARATIONSIDE 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 SQ. .SIZE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. 1/ NEW ❑ BK PG 0_ VALUATI0 mD 0 License Number Lic.Class DESCRIPTION OF WORK.� ��. ADD ❑ $ � ©� � Contractor Date 0� ALTER ❑ cc I ftp $ REPAIR ❑ $ O ElI am exempt under Sec. BAP.C.for this reason ( Gli7 DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. / Z GJ2URM El (L Signature ' 7` APPLICANT(PRINT) LDMA Perm# CCT. ' 8 Z 1 as owner of the property, or my employees with wages as ' - w i lap,�� ' Z ACCT e'B their sole compensation, will do the work�and the structure is s� ��-+�y A � Z [ PCS i C %� !� FINAL DATE f O 33503 125.55 not intended or offered for sale (Section 7044, Business and �J /meq G Professions Code.) WILL THE APPLICANT A FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL S b� J _ 1 ITEM GI IJ ❑ 1, as owner of theOR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY �! TI"ITAL ��@ licensed contractors to construct the project (Section 7044, -"--" m Business and Professions Code.) ves El No ( i WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK 125.55 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH LI ('� {�(y CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR CHANGE .00 GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ No❑ w the performance of the work for which this permit is issued(Sec. IHAVEREADTHE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING � _��� +i` ��p7C 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS EL+ � Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 3649 L 1 Q i A�i i.1? o Lender's Address O'F7 1 F! 11 1J 0 OWNER OR AGENT _ o , I certify that I have read this application and state under penalty 0. of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE with all county ordinances and State laws relating to building VX m constructs n; and here y authorize representatives of this County SSUANCE FEE to enINVESTIGATION FEE TOTAL FEE O t o v mentioned property for inspection purposes. a � C S C� Signature I5f AXi4nl or Agent Defe •"7 ' ✓J SEE REVERSE FOR EXPLANATORY LANGUAGE