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Home My Public Portal About10714 ARROWOOD ST_Building_6/16/1993_new patio cover APPUC AMON FOS oULONG PERNT COUNTY 45F-LOS-.ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION. FOR APPLICANT TO FILLIN BUILDING ADDRESS ; I hereby affirm that I have a certificate of consent to self insure, BUILDING DRESS 7 1rte` " � nd or a certificate of Workers' Compensation Insura ce,or a certified r0�� copy thereof(JSec.3800,Lab.C.), �` - ZIP _ �Y+'I LOCALITY Policy No. IJ Compan SIZE OF LC NO.OF BLDGS.NOW ON LOT Certified Copy is hereby furnished. NEAREST CROSS ST. Ll Certified Copy is filed with the County building inspection TRACT BLOCK LOT NO. �''�Q. depart Ent. hl�L/ /�/1 M, - - USE ZONE MAP NO. Date q I/ -Applicant O //�lil!/ / IYI� ASSESSOR MAP BOOK AGE ` PARCE ,//� / 7_ -.7-77, .• ,�), -� '7�� T (,> _ /Y — / SPECIAL CONDITIONS ✓ / _ - - ' CERTIFICATE OF EXEMPTION FROM WORKERS' R/ ry/�� COMPENSATION INSURANCE QW Pf WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS M 7/ �� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100) or less.) _ ' s ZIP I certify that in the performance of the work for which this permit t/-� is issued, I Shall not employ any person in any manner SO as t0 ARCHITECT ENGINEER TEL NO. become subject to the Workers'Compensation Laws. STATISTICALCL6LSSIFJCATION 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' CONTRACTORC I E N�° /� j SET BACK ''YARD , -HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith / � 577 0/ � FRONT comply.with such provisions or this permit shall be deemed revoked. 9DD Et;S i� P L , ke_ LICENSED,CONTRACTORS DECLARATION (C PILE CYC n LAyS,S P L I hereby affirm that I am licensed underprovisions of-Chapter 9 f''rV _a! SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO FT.SIZE NO.OF STORIES NO.OF FAMILIES - Professions Code,an my license is in full force and effect. NEW BK PG' D a- License NU er r� Lic.Class DESCRIPTION OF WORK - ADD ❑ VALUATION O +� L�d 0 Contractor F Date �� ALTER ❑ $ ` ©Q- ❑ I am exempt under Sec. REPAIR. ❑ $ 0 B.&P.C.for this reason DEMOL ❑ LDMA P7C#' LU URM ❑ Date: -USE OF EXISTING BLDG. — , U) Signature _ APPLI AN PR/NT) EL a�AJ�lCL_� �� LDMA.,Perm#. t• 'k'f '•+. Z_ El 1, as owner of the property, or my-employees with wages as //' �!y t Z0, I °�• :t i T their sole compensation, will do the work and the structure is AD Sff. ` - , u 1 �,,{:q �; not intended Or offered for sale (Section 7044, Business and W I Q' /} s FINAL DATE ! Q 'i Wt 3 °'=-3 Professions Code.) y Q WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE'A HAZARDOUS MATERIAL 4/:�2/�3 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ 1, as owner of the property, am exclusively contracting with -. FINAL BY > - AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? •' - ' licensed contractors to construct the project (Section 7044, YES❑ No { Business and Professions Code.) } - WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR �--, GUIDELINES. - •i ITEM .�f 1 hereby affirm that there is a construction.lending agency for YES❑ NO` } a {� ,N the performance of the.Work for which this permit IS Issued(Sec. IHAVE READ THE AROOUS MATERIALS INFORMATION GUIDE AND THE SCA QMDPERMITTING TOTAL 1 _e.._..m 8.• m 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, '"' "" `' ._ a TITLE 2,CH TER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS - CHECK 15 i°is f Lender's Name MATERIAL P ND FOR OBTAINING A PERMIT FROM THE SCAQMD: o Lender's Andress CHANGE ,i 1 i O - OWNER 0 AGENT o I certify that I have read this application and state under penalty q 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 Sa �/ f1J[i_I— f�3 6 16.!7i3-, m construction, and hereby authorize representatives of this County ISSUANCE FEE --- - .. ......:.. _ t nt upon the a ve m ti ned property for inspection purposes. �I•%L�;' 1 jy if f*W _ INVESTIGATION FEE TOTAL FEE i 9 mea I oo, m o� qem Dale D SEE REVERSE FOR EXPLANATORY LANGUAGE