HomeMy Public PortalAbout9173 JAYLEE DR_Building_5/17/1993_reroof APPUCAMON FOR BULMNIGPERMF
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING ADDRESS
WORKER'S COMPENSATION.DECLARATION '
I hereby affirm that I have a,certificate of consent to self insure, BU I ING A DRESS �� Q( 7
or a certificate of Workers'Compensation Insurance,or.a certified
copy thereof(Sec.3800;Lab.C.) Y ZIP
LOCALITY
Policy No: Company SIZE OF L T NO.OF B DGS.NOW ON LOT
❑ NEAREST CROSS ST.Certified copy is hereby furnished. "
❑ Certified copy is filed with the-county building inspection TRACT BLOCK LOT NO..
USE ZONE MAP NO.
department. ,
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS ,
CERTIFICATE OF EXEMPTION FROM WORKERS' NER
WITHIN 1000 FT OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred DDf?ESS
dollars($100)or less.)
(,? DISTRICT GROUP TYPE CO ST. FIRE ZONE PROCESSED BY
CI Y IZIP e
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so.as to
[ARCHITECT-IVR ENGINEER TEL NO. w
become subject to the Workers'Compensati/J/(�Laws. STATISTICAL C_LA+SJ�I�FICATIO APT CONDO
Date S7/7- - Applicant s (/r_ 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 S o.J FRONT
comply with such provisions or this permit shall be deemed revoked: ADDRESS LIC.NO. PL
LICENSED CONTRACTORS DECLARATION I yr LIC.CL SL PILE
-c+I,TY.� � - LIC.CLASS PL -
I hereby.affirm that I am.licensed underprovisions of Chapter 9 ""`�"'��` e, C 3 �� SEWER MAP
(commencing with Section.7000)of Division 3.of,'the Business and SQ.FT.SIZE / NO.OF,STORIES NO.OF FAMILIES
Professions Code,ffail�ie�1d my license is in full force nand effect..
• t NEW ❑ BK PG
License Number F9� O � Lic.Class ` -3-I DESCRIPTION OF WORK ZS ADD ❑ VALUATION.
Contractor <� Date S—/��f'3 ALTER ❑ $ 2c��
❑ I am exempt under Sec. REPAIR. ❑ $ 0
B.&P.C.for this reason DEMOL ❑ LDMA P/C# W
Date: USE OF EXIS ING BLDG. URM ❑
CO
Signature I Z
Ap/,p�I)CrANT(PRINT) � � TEL N - LDMA'Perm#
❑ I, as.owner of the property, or my employees with wages as ""���� 4/� NL'•'�^/ �' ZO i'(; AV
•their sole compensation, will do the work and the structure is
ADDRESS Ate•_t a a
not intended or offered.for saleSection 7044, Business and �! !Z N W"1)/'Ci CL;. FINAL DATE I "•.f 307
( z ..CII 2 Q J� 117.9-0
PfOfeSSlOnS Code.) - WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ITEMS
1{{ MS
El 1, as owner of the property, am exclusively contracting with
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE .EAMOUNTS SPECIFI D ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY _,
licensed contractors to construct the project (Section 7044, YES❑ NOI i ITAL 117 -90
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING CHECK 117.90
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY,MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR i/-C
GUIDELINES. - , CHANGE .00
I hereby affirm that there is a construction lending agency for YES 1:1No v
a the mance Of the Work for which thispermitIS ISSUed(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING y
30977,,Civ.
IV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, �-
w TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS Ih,]I]r—I�I]LI I Jam;
3 Lender's Name M LS REPORT G AND FOR OBTAINING A PERMIT FROM THE SCAQMD. '
o Lender's Address9 f 1 Ali If l a cc
a�i.�
NER OR AGENT
o I certify that I have read this application and state under penalty.
O 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 Z 47%
< construction, and hereby authorize representatives Of this County - ISSUANCE FEE
00
to to ntfer upon t above-mentioned property for inspection purposes. r7��
a ��/�q�-�', 16_/^t_Qom? INVESTIGATION FEE TOTAL FEE / Q
cD ///+s+�yaaa /
Ski'�naWr f oliwni or Agent Data I "
SEE REVERSE FOR EXPLANATORY LANGUAGE