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Home My Public Portal About5828 BURTON AVE_Building__ �l WORKERS COMPENSATIODECLARATION N • insv Sy ,,,�em fica 1 ofWor cdrtCome of consent to self APPUCAMN FOR BUILDONG PEMM 11 _^ .insure la'�errii tale of Workers' Compensation Insurance, �' orva den \�EOPy I'ereof,(Sec 3000,'Lab. C ) - - - - COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo._ -` •Company tr - --yy----- Garf Ted copy is hereby furnished. ' FOR APPLICANT TO FILL IN BUILDING IDDRESS '� � Lief Ll LC/ `Certi•'ed copy is filed with the county building inspec- BUILDING q '' tion c->portment. ADDRESS U Date_)7 t .Applicant CITY / ZIP l �7 7� LOCALITY +CEt?;jpICATE OF EXEMPTION FROM WORKERS' - ' NO.OF'BLDGS. NEAREST - f 'COMPENSATION INSURANCE SIZE OF LOT -'1 X•S' l NOW ON LOT CROSS 5T. (This seen.need not be completed if the permit is for one - ASSESSOR I or less. TRACT BLOCK LOT NO.- - MAPBOOK PAGE PARCEL hundred` ollars ($100, ) - - d EL. / I Corti fy hdh in the erformance of the work for which this plissued, I shall not employ any person in any manner OWNER �/ NO. `'{Oc]-p Nl t7 USE ZONE OP J imiIji's. AA �, SPECIAL ADDRESS ,j � !.i CONDITIONS so ids fo become subject to the Workers'Com a cation laws. U \ c ��/v�tZJ.r CITY ZIP J� Oate Applicant ;NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR - TEL. r DISTRICT I GROUP TYPE FIRE ESSED By O Exariptjon, you should become subject to the Workers' ENGINEER NO. I.— yam/) CONST./ ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS V(/ 1A —3 with comply with such provisions or this permit shall be - LLJ _ TEL.- _ STATISTICAL CLASSIFICATION APT. CONDO- U) •dear�ed.revoked. CONTRACTOR NO. 1 ' Z LICENSED CONTRACTORS DECLARATION LIC. CU155 NO.�LDWELL UNITS_' 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and 11.LIC - SEWER MAP r—prfofessions-CoBe, and my license is in full force and effect. CITY y CLASSL VALIDATION 50. F. NO. OF / NO.OF / CHECK BKJ PG-63 'L'c ense.Number Lia Class SIZE STORIES 1 ` FAMILIES ,.V ONE I ' VALUATION t DESCRIPTION OF WORK NEW ntractar1 � Date ,/�T� ADD � sl�bi ✓ +� +� E� I am exempt under Sec ' 7 40 �Qt D { I ALTER ❑ J B.&P.C. for this reason REPAIR : - + i Date: USE OF DEMOL if EXISTING BLDG. - 1 APPLICANT TEL. Signature FINAL (` a r PRINT NO. A.CT.T OWNER-BUILDER DECLARATION DATE ro•-(� _ 1 I.hereby.affirm that I am exempt from the Contractor's License ADDRESS - FINAL ee07 _ 22.9 Low or the following reason (Section 7031.5, Business and 22.9.L.1131 Professions Code): - - 9y 1 ITEMS BUILDING I, as owner of the property, or my employees with ADDRESS t' TI�iAL �� wages as their sole compensation;will do the work and _ LOCALITY the structure is not intended or offered for.sale(Section - ,'+ CHECK 228. ICI 7044, Business and-Professions Code). MOVING TEL ®� n a I,•os owner of the property, am exclusively contracting CONTRACTOR NO. -" CHANGE .1-10 with licensed contractors to construct the project (Sec-. ADDRESS - - tion 7044, Business and Professions Code). i REQUIRED TOTAL SETBACK CONSTRUCTION LENDING AGENCY SET BACK YARD HWV - PROP. LINE WIDTH JCILTI I-QCIC11 j11��,'�,tJ i I hereby affirm that there is a construction lending agency for FRONT I�;Y.f O;e 1 the performance of the work for which this permit is issued P.L. 1 AM �. (Sec 3097, Civ. C.). SIDE P.L. t Lender's Name IDMA Ref. N Lender's Address I.C. Fee E Permit Fee �l D I certify that I have read this application and state that the Iswonce Fee 'O v LDMA P/C if - 11 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee;,? -2, k,, _ LDMA Perm. X R and hereby ouihorize representatives f this County to enter ve property/T inspection purposes. _7, ( �JJ SEE REVERSE FOR EXPLANATORY LANGUAGE ,`.� Signature of Applicant or Agent Dote APPLICATION FOR BUILDING PERMIT g COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION ` FOR APPLICANT TO FILL IN BUILDING ADDRESS i I hereby affirm that I have a certificate of consent to self insure, \ BUILDING ADDRESS or a certificate of Workers Compensation Insurance,or a certified copy thereof(Sec 3800,Lab.C.) CITY ZIP LOCALITY Policy NO. Company SIZE OF LOT NO.OF SLDGS.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. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? ves No (This section need not be completed if the permit is for One hundred ADDRESS ' { .�.. DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars($100)or less.) CITY ZIP - f 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 become Subject t0 the Workers Compensation Laws. ARCH ITECT OR ENGINEER TEL NO. ! � STATISTICAL CLASSIFICATION APT CONDO DateApplicant ADDRESS CLASS NO, DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of - 1 REQUIRED TOTAL SETBA K FROM EXIST Exemption, you should become Subject t0 the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP*JE�� f WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC,NO. P L �::f �.`• , LICENSED CONTRACTORS DECLARATIONSIDE . hereby affirm that CITY LICCLASS P L am licensed underpfoviaions of Chapter 9 - SEWER M R 1 14 Q (commencing with Section 7000)of Division 3 of the Business and SO.FT SIZE NO.OF STORIES NO.OF FAMILIES -L�. Professions Code,and my license is in full force and effect. i -:; NEW ❑ SK PG STGf.� �` 1 'LU License Number LIC.Class DESCRIPTION OF WORK , ADD A VALUATION , "W4411 Contractor ALTER ❑Date - $ rRATA _LL ❑ 1 am exempt under Sec. REPAIR ❑ $ }'+7rJfJ1 BAP.C.for this reason - DEMOL ❑ s,p IX UDMADate: USE OF EXISTING BLDG. URM ❑ P/G x ! �! 1'fI DO"' Signature APPLICANT(PRINT) TEL NO. LDMA Perm A A4JI) i Ul ❑ 1, as owner of the property, or my employees with wages as ZO • ~ their sole compensation, will do the work and the structure is ADDRESS F �C�•t.". not intended or offered for sale (Section 7044, Business and FINAL DATE Q Professions Code.) WILL THE URE CAM OR FUTURE HAZARDOUS OCCUPANT UAL T A HAZARDOUS MATERIAL 'RrI-N as ownero Of the property, am exclusively contracting Hng 44, OR A MIXTURE CONWINI THE A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE a gyp'•� i / 71 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERNLS INFORMATION GUIDES FINAL BY �j i 1d?A Business contractors t0 construct the project (Section 7044, YES❑ NO❑ Business and Professions Code.) .l OTAC �!� OCC THE INTENDED USE OF THE BUIDUNGONSTR BY THE MODFINT OR FROM T BUILDING SOUTH S230•n l OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION(CTION OR EE PERATION CH THE SOUTH J4 X/ CONSTRUCTION LENDING` AGENCY COAST AIR OUALRY MANAGEMENT DISTRICT ISGAGMD)SEE PERMRTING CMEGCUST FOR GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ No❑ •((�yy m the performance Of the Work for which This permit is issued(SOC. IHAVE READ 111E HA24RCOUSMAIERIALS INFORMATIONGUIDE AND THE SCAOMD PERMITTING •L" 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 220 SECTIONS 2.20.100 THROUGH 2.20 140 CONCERNING HAZARPROUS Lender's Name MATERIALG REPORTING AND FOR OBTAINING A PERMIT FROM THE GCAGMD. ��••y�/yyy�, Lender's Address p FaNer OR AGENT o I certify that I have read this application and state under penalty i� ,u� O of perjury that the above information is correct.1 agree to comply P.C.FEE PERMIT FEE +.A,7 AM 102 V N with all county ordinances and State laws relating to building am COnstructich, and hereby authorize rpesentatives of this County ISSUANCE FEE to enter upbn the above-mentioned pI perty for inspection purpos2y5e < INVESTIGATION FEE TOTAL FEE I` u,,,wre a rom�m e.roil Dere SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT Gc� COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILLING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS or a certificate of Workers'Compensation Insurance,or a.certified copy thereof(Sec.3800, Lab.C.) CITY ZIP i 'I - 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 tpe county,building inspection TRACT BLOCK LOT NO. department. l USE ZONE MAP NO. ASSESSOR MAP BOOK PAGE PARCEL I / ,p7 Date ' Applicant � ,�� ' �;i�--'�- vv SPECIAL CONDITIONS CERTIFICATE OF EXE_ TION FROM WORK9.RS' OWNER TEL No. ves No COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? (This section need not be completed if thermit is for one hundred ADDRESS I>e DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100) or less.) CITY ZIP --- 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 become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO. S STATISTICAL CLASSIFICATION 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 TEL NO. SET BACK YARD HW V PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS UC.NO. PL LICENSED CONTRACTORS DECLARATIONSIDE > CITY LIC,CLASS PL I hereby affirm that I am licensed underprovisions Of Chapter 9 SEWER MAP 0 (commencing with Section 7000)of Division 3 of the Business and SO.FT SIZE NO,OF STORIES NO.OF FAMILIES 0 Professions Code,and my license is in full force and effect. I r NEW ❑ SK PG W License Number Lic.Class DESCRIPTION OF WORK ADD ❑ VALUATION , J Contractor - Date ALTER ❑ $ LL ❑ I am exempt under Sec. REPAIR ❑ cc$ B.&P.C.for this reason DEMOL DMA P/C# Date: USE OF EXISTING BLDG. URM 11d Signature APPLICANT(PRINT) TEL NO. LOMA Perm# W ❑ I, as owner of the property, or my employees with wages as Z } �� ~ their sole compensation, will do the work and the structure is ADDRESS �p �L rot intended or offered for sale (Section 7044, Business and FINAL DATE Professions Code.) WILL THE APPLICANT OR FUTURE BUIUMNG OCCUPANT HANDLE A HAZARDOUS MATERIAL J ! T-1-C`tK OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 1 l f G.!F7 ❑ I, as owner Of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERALS INFORMATION GUIDE? FINAL BY 9 licensed contractors to construct the project (Section 7044, YES❑ NO❑ TOTAL 1.88 . 10 Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING INA � f[I OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MOOIFICATON FROM THE SOUTH yUgFU/ CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT ISCAOMDI SEE PERMITTING CHECKLIST FOR / GUIDEUNES - I hereby affirm that there is a construction lending agency for YES❑ NO❑ TN the performance Of the Work for Which this permit Is Issued(See. IHAYER.EAD THE RAZARDOUSMATERIALSINFORMATIONGUIDE AND THE SCAOMOPERMITTING T 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. 3 TITLE 2,CHAPTER 220 SECTIONS 2.20.100 THRWGH 2.20.140 CONCERNING HAZARDOUS Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMID YLWr o Lender's Address o a NEN m wom 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 with all county ordinances and State laws relating to building ro construction, and hereby authorize representatives of this County ISSUANCE FEE to enter upon the above-mentioned property for inspection purposes. INVESTIGATION FEE TOTAL FEE ^ sp' re cRrow�nl o,M/n� cbe SEE REVERSE FOR EXPLANATORY LANGUAGE y -" • COUNTY OF_LOS ANGELES .: ,BUILDING-AND SAFETY WORKER'S COMPENSATION DECLARATION - FOR APPLICANT TO FILL IN I BUIL I BUILDJyc�A DR ss /t _V 1 � I hereby affirm that I have a certificate of consent to self insure,- .LJ- T le✓tIV� ,�,, or a Certificate of WorkersCompensation Insurance, or a certified - - copy thereof (Sec.L3800,Lgab�C.) . 1 CITY w - 9"t IP •LOCALITY - -Policy No./ f,7�L^ COmpanyc"F SIZE Or F LOT I�� NO.OF Bl_ /S,NOW ON LOT ❑ Certified copy is hereby furnished. /—� 6 NEAREST CROSS SIT ❑ Certified copy is filed with cou y uiltling inspection THAOT BLOCK - LOT NO, department . USE.ZONE MAP N0. Date —J1 1 Applicam I ASSESSOR MMP BO K PAGE PARCEL - OO SPECIAL CONDITIONS CERTIFICATE OF EX N FROM WOR S' - OWNER ' - TEL NO. COMPENSATION INSURANCE _WITHIN 1000 FT.OF SCHOOL? "YESNo (This section neednot be completed if the permit is for one hundred ADDRESS - - - - dollars($100) or less.) .- DISTRICT GROUP TYPE CONST: FIRE ZONE PROCESSED BV CITY- - ZIP y , certify that in the performance of the work for which this permit trio is issued I Shall not employ any person in any manner.so a5 t gftCHly�CT ORppENGINEER-• TEL NO. "e—J become Subject t0 the Workers'Compensation'Laws. F?S.I T} eR IL� C �Il STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRES ./ �p .y/y,� GLASS NO. DWELL UNITS NOTICE TO APPLICANT.. If, after making this Certificate of 017 W1 Ulht- 4 - 7„1 Ol r REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject -to the Workers' CONTRACT TE NO. SET BACK P Y 1 YARD .HWV PROP LINE WIDTH Compensation provisions of .the Labor Code, you must forthwith p I J ✓�N W I �0/ G; rL13 FRONT comply with such provisions or this permit shall be deemed revoked.. p DUESS LIG NO, P L LICENSED CONTRACTORS DECLARATION q'Vp 5� 41614. PILE I hereby affirm that I am licensed underprdvisions,.of Chapter 9 GT � � � AGC�Z_G12 ( SEWER MAP (commencing with Section 7000)Of Division 3 of the Business and SO.FT SIZE .NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW ❑ BK PG D _ IL License Numbeer�L�J��.�7/apr Lic. Class 4 -11-C� DESCRIPTION OF WORK .(ADD ❑ VALUATIO Q HiTf610f I B W Date Y 1-INo1J v RewLa, AL $ o Contractor - ALTER ❑ bF S-Muctwc_ ¢ ❑ 1 arrexempt under Sec. _ REPAIR .O $ 0 B.&P.C. for this reason DEMOL LDMA P/C a . - W Date: USE OF E STINGBLDG ' URM EL �sI;,D x m Signature .Q APPLICANT(PRINT) TEL NO. LDMA Perm k 1 Z ❑ I, as owner of the,property, or my employees with wages as - ZO ACCT i their sole compensation, will dothework and the structure is ADDRESS to not intended or offered for sale (Section 7044, Business and FINAL DATE Q3303 188.10 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL _ O - OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 1 ITEMS as;dwner Of the property, am exclusively contracting with FINAL BY_�� IIOanSed.contractors to Construct the prolaCt (S2CIlOn 704¢, AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? ,'T 188 pp { Business and Professions Code.) YES El NO❑ . TOTAL 1rlS _ j.�I''� � yti OWILLCC THE INTENDED USE OF THE BUIDLINR BY THE APPLICANT OR FUTURE BUILDING (•LI[/`I/ ` i60• �f} OCCUPANT REQUIRE A PERMITMANAGEMENT FOR CONSTRUCTION Ip MODIFICATION FROM THE SOUTH / �/ A4•yfIEFIIY/j❑irG- 1130 L�II/Jf -CONSTRUCTION LENDING AGENCY \\ coast AIR ounury MArvncsmervr DISTRICT IscnaMopSEE,PERMOnrvc cHEcrcusT FGR /(( - Y 'YES EUNEs I heieby affirm that there is a construction lending agency for YES El NO the,performance of the work for which this permit is issued(Sec. W - I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ' 3097,CIV.Ci.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. TITLE 2,CHAPTER 220 SECTIONS 2 20.100 THROUGH 220.140 CONCERNING HAZARDOUS 3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMO. o Lender's Address avrlee oe ACFu, �J_��,�J 10 1 1'NI "' oI certify that i have read this application and.state agree to penalty o ,PC.FEE PERMIT FEE {D of perjury that the above information is correct. I agree to comply Gj with..all county ordinances and State Maws relating to building - monstr_uction, and hereby authorize representatives Of this County - - ISSUANCE FEE - ;� ent un the above-mention roperty for inspection purpose - ,�y/ INVESTIGATION FEE TOTAL FEE/ O �Q O I SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICAMON F®R BULDNIG PERNT ] _ COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN "Bron: D DDpgEss - I hereby affirm that I have a certificate of consent to.self insure,. BUILDING AHESS or a certificate of WorkersCompensation Insurance,or a certified { v copy thereof (Sec.3800,Lab.,G) F IF e I ' �T 4`� l p. •T LOCALITY: Policy.No. Company - - - - +G - `N\ F LO /� .� NO,OFBLDGS..NOW ON LOT❑ Certified copyis hereby furnished _ - V .t'l V-:' NEAREST CRosS T:❑ Certified copy is filed with'ihe county building inspection \ ,!"-- BL CK LOT NO, USE ZONE MAP NO. department. ) _ Date Applicant ASSESSOR MAP BOOK PAGE PARCEL - SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ]n ( TEL NO. -U/ COMPENSATION INSURANCE - •" WITHIN 1000 FT.OF SCRoota YES No ' (This section need not be Completed if the permit is for one hundred ADDRESS - -, - •Z� b-i1Z��tJ ' / DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars'($100)br less.) " � `�� V , - CITY - ZIP I certify that in the performance of the Work for which this permit L _ �(''O� is issued, I shall not employ any person in any manner so as tc` ARCHITECT ENGINEER TEL NO. i .J v• become subject to the Workers'CompenSatiOr Laws. - , i - STATISTICAL CLASSIFICATION APT CONDO 1 Date Applicant RE S GLASS NO. DWELL UNITS - NOTICE TO APPLICANT.. If, after making this Certificate Of. '7� "` �I L� l C Y REQUIRED TOTAL SETBACK.FROM. EXIST Exemption, you Should become subject to the Workers CQ ACT R - TEL NO. GET BACK YARD HWV PROP LINE-,- - WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT -- ' .,f comply with such provisions or this permit"shall be deemed revoketl. ADD S LIC.No.-, pL -`�": -- b u rd•�1 U LICENSED CONTRACTORS DECLARATION _ SIDE 1 1 CIT Al K/1 LIC.CLASS hereby affirm that I,am licensed underpmvisions.of Chapter 9 � " I .SEWER MAP T "- (commencing with Section 7000)of Division 3 of'tfie Business and SO.FT SIjE NO.OF STORIES N0,OF FAMILIES Professions Code,and my license Is in full force and effect. L C(� Z NEW `❑ SK PG D License Number I Class D CRIPTI G oRK ADD VALUATI N I - (� Ill Li .Contractor Date 1 ALTER ❑ $' 1\ > ❑ 1 amexempt under Sec. ^+ REPAIR ❑ B.&PC. for this reason 1` �, h) DEMOL ❑ i,Y} - L LOMA P/C# js �)I LU Date: \\, URM ❑ ACCT.g Signature 5 APPLICANT(PRWT) _ _ TEL NO L_DMA Pum# 3J0; ' Z ❑ 1, as owner of the property. or my employees with wages as fff��V - Z - �(/•� �� their sole compensation, will d0 the Work'and the SIfUCfUre l5 ADDRESS FINA O I r nbC�1 .j not intended or offered for sale (Section 7044, Business and t t Q - Professions Code.) ❑ WILL THE APPLICANT OR FUTURE eUILUNG OCCUPANT HANDLE A HAZARDOUS MATERIAL 1I ./ OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J - I as owner of the property, am exclusively contracting with A > 3303 y� AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFOPMATION GUIDE? f Tcensed contractors to construct the protect (Section 7044, . . 2`2e.14 ES❑ NG❑ ITEMS Business and Professions Code:) - � - 2 WILL THE INTENDED USE OF THE BUIDLINR BY THE APPLICANT OR FUTURE BUILDING TOTA1 OOASTA IR REQUIRE TY A PERMIT FOR CONSTRUCTION D) MODIFICATION FROM THE SOUTH '.4d ., L11.. La2TOv 15,1 '- - CONSTRUCTION LENDING` AGENCY — - - 1 COAST AIR OUAUTY MANAGEMENT DISTRICT ISCAOMD)BEE PERMITTINGbHEGKUST FOR 'w ,•.. O 4141 - culoeurves Lr v - I hereby affirm that there is a construction lending agency for YES El No El - CHECK 3230 .m the performance of the work for which this permit is issued(Sec. CHANGE •00 3U9T,4)IV.C. I HAVE READ THE HAZARDOUS MAT BRATS INFORMATONGUIDE AND THE SCAOMO PERMITTING voo N ") _ CHECKLIST.I UNDERSTAND MV REOUIPEMENTS UNDER THE LOS ANGELES COUNTY CODE TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.1 aO CONCERNING HAZARDOUS 3: Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. o Lender's Address - - 0000-0001 [' c QNNEP OP.GE l S/1- 9.5 o I certify that I have read this application'and state under penalty {� Z Of erur that the above information is correct.I a roe t0 COm PC.FEE /� 9 PERMIT FEE � 1G' AM10 N with all polity ordinances and St laws relat ng to building 1 -� 57 1 '12 m constructio d hereby authorize r p esentativea of this County �� (e ISSUANCE FEE m to nter TO t e ab91 e-mentioned pr rty for ins action purpgseS. — / D - j S INVESTIGATION FEE TOTAL FEE -r[/q-.� / '- m f ,1N• cJ of 1 .. SEE REVERSE FOR EXPLANATORY LANGUAGE f -