HomeMy Public PortalAbout10636 OLIVE ST_Building_8/22/1995_REROOF APPLICKhON FOR BUILDING PERMIT
s° COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING A 2E�
BUILDING ADDRESS S
3�
I hereby affirm that I have a certificate of consent to self insure, 10636 Olive
'
or a certificate of Workers'Compensation Insurance,or a certified M
copy thereof(Sec.3800,Lab.C.) 0"Templa City ZIP LOCALIT(y ///JJ9
Policy No. 757144 CompanyS t a t? F»n d SIZE OF LOT NO. BU7GS.NOW ON LOT \s J
❑ Certified copy is hereby furnished. NEAREST CROSS ST.
® Certified copy is filed with the county building inspection TRACT __7_
LOCK LOT NO.
department.
USE ZONE MAP NO.
Date .5 Applicant Mnna rnb+ Unnf i ng ASSESSOR MAP BOOK PAGE PARCEL
I SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' ON1NERLeona Jackl
Yes "N NO
COMPENSATION INSURANCE y WITHIN 1000 FT.OF SCHOOL? o
(This section need not be completed if the permit is for one hundred ADDRES.10 6 3 6 O l lve
DISTRICT GROUP E
FIRE ZONE PROCESSED BY
dollars($100)or less.) CITY � g1
I certify that in the performance of the work for which this permit Temple City Qf/> `�/(
is issued, I
-shall not employ any person in a manner so as to
become subject to-the Workers'Compensation LAWS. ARCHITECT OR ENGINEER TEL NO. �/Gt ,
STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS - CLASS NO.. DWELL UNITS .
NOTICE TO APPLICANT• If, after making this Certificate of REQUIREDTOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR_arch Roofing 7§18=6191 SET BACK YARD HWY PROP UNE WIDTH
Compensation provisions of the Labor Code, you must forthwith FRONT
comply with such provisions or this permit shall be deemed revoked. ADDBESS 2 E. Walnut,nut, S Ll i t uC No. P L
L41 "391983 SIDE
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed underprovisions of Chapter 9 CIT a S a d e n a ss P L
(commencing with Section 7000)of Division 3 of the Business and
SQ.FT.SIZE NO.OF STORIES NO,OF FAMILIES SEWER MAP }•
rL
Professions Code,and my license is in full force and effect. NEW BK PG
License Number 3 919 8 3 Lic.Class C-39 DE RIPTION OFADD ❑ VALUATION
emovew t`l.ree roofs.
Contractor . Monarch' Data 6/8/95 ' pp y e an ALTER C1 � 1,900.00
LU
❑ 1 am exempt under Sec. REPAIR ❑
BAP.C.for this reason I DEMOL ❑ LDMA P/C#
Date: USE OF EXISTING BLDG. URM ❑
g Residence
Signature APPLICANT(PRINT) TEL NO. LDMA Perm# �ea 108.90
❑ I.-as owner of the property, or my employees with wages as Monarnh Roof ina 1796-6191
Z
their sole compensation, will do the work.and the structure is ADD2Vi2 E. Walnut Suite D a
not intended or offered for sale (Section 7044, Business and FINAL DATE WILL THE APPLICANT OR FUTURE
Professions Code.) BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL `�2—�
J
E] I, 83 owner of the proper , am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 1 ITEMS
tyAMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project (Section 7044, YES❑ NO IM
Business and Professions Code.) TOTAL TOS o 90
WILL THE INTENDED USE•OF THE BUIDUNG 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(SCAOMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES
I hereby affirm that there is a construction lending agency for YES❑ NOA CHECK 108.90
a the performance of the work for which this permit is issued(Sec.
CD I I HAVE READ THE.HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING
3097,CIV•C.) CHECKLIST.I U RSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE.
CM TITLE 2.CHA 2.20 CTIONS 2. 00 THROUGH 2.20.140 CONCERNING HAZARDOUS
a Lender's Name MATERULLS Q AND'FOR ING A PERMIT FROM THE SCAOMD. CHANGE
ono
C3 Lender's Address OWNER f E V
0
o I certify that I have read this application and state under penalty
of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
N with all county ordinances and State laws relating to building �J/
m construction, and hereby authorize representatives of this County 11SSUANCE FEE 1 O —OOQ11 0 81
ro o en upon the above-6&oned property for insp ctio puAt.r . es. J
a
nINVESTIGATION FEE TOTAL FEE
S .'b1 APDUCW m M Data !J
SEE REVERSE FOR EXPLANATORY LANGUAGE