HomeMy Public PortalAbout10726 DAINES DR_Building__ COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S.COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
BUILDING ADDRESS
I hereby attire that I have a certificate Of consent to self insure �D-'7 a In
of a certificate Of Works Compensation Insurance,Or a certifie�
SPY thereL eG-3�j)9 7rpany
v'v / CITY _ t ZIP - �� .
W1
� I ei�, f� G L LOCALITY
Policy N OrnSIZE OF LOT 'NO.OF BLDGS.NOW ON LOT
❑ Certifi opy is hereby furnished. NEAREST CRO ST
Ified copy is filed With the pection TRACT BLOCK LOT NO.
departm nt. USE ZONE MAP NO.
9 O FSSO MAP j PAGE PARCEL
Dat¢ Applicant 5 i .SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FR WORKERS'- wNP M D L y. YES NO
COMPENSATION INSURA CE WITHIN 1000 FT.OF SCHOOL?
ADDRESS -
(This section need not be completed if the permit is for one hundred OU L' - DISTRICT -GROUP TYPE CONST.' FIRE ZONEROCESSE Y
dollars($hat)i Hess.) Clio ,ZIP BOY
01
`� � )
I certify that in the performance of the work for which this permit {✓1 l/O/
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO.
become Subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CKDO
Dale 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' G RACTpfl, L.Np. �� SET BACK YARD HWY PROP LINE "WIDTH
Compensation provisions of the Labor Code, you must forthwith 11// G FRONT
comply,with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL
S—I'�t-0 CL lQ "f C1 �v3 r
LICENSED CONTRACTORS DECLARATION CITY t LIC.CLASS pIL E o
I hereby affirm that I am licensed under provisions of Chapter 9 � � SEWER MAP U
(commencing with Section 7000)of Division'3 of the Business and ++SA�O.SFT/gIZE NO.OF ?ORES NO.OF FAMILIES
Professions Code and m rise is in full force and effect. 3 Y 90 - NEW ❑ BK PG U
�' ��„4 DESCRIPTION OF WOR ADD ❑
License Number Lic.Class �f VALUATION
Contractor Com' �- Date -ALTER $ ® J Z
❑ I am exempt under Sec. REPAIR El
B.&P.C.for this reason rT DEMOL ❑
_ LDMA P/C p
Date: USE OF EXISTING BLDG. URM ❑
Signature APPL ANT(POINT) J TEL.NO. LDMA Farm M },
❑ 1, as owner of.the property, Or my employees Willi wages as L6TY'� � ftlVSo O= r, a
their sole compensation,will do the work and the structure is ADDRESS F ACL I .T
not intended Or offered for sale (Section 7044, Business and FINAL DATE Q
Professions Code.) O _�I�J 1a°01+
I r WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J _
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN a { T N!
1❑ I„as owner Of the property,.am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL 7 + 1)EII�'
licensed contractors to construct the project (Section 7044,
Business and Professions Code.) Ya❑ NO
❑ i I I AL m �
WILL THE INTENDED USE MI THE BUILDING BY THE APPLICANT IO FURORE BUILDING _
OCCUPANTOASTIR REQUIDUALITY
MANAGEMENT
DISTRICT
RS NORMODIFI PERMITTING
FROM THECOLITH 1 L� �'{� '7 i
CONSTRUCTION LENDING AGENCY CWS?AIR QUALITY MANAGEMENL DISTRICT(SWOMDI SEE PERMITTING CHECKLIST CAICK ��+� S
- ' • J } - FOR GUIOELINEa. L
I hereby affirm that there is construction lending agency for YES❑ NO❑ - �-� �� 1+f IANaE °IJO
the performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SWOMD
3097,CIV.C.). PERMITTING CHECKLIST.IU UNOFASTAND MY REQUIREMENTS UNDER THE LOS ANGELES ( 5
3-m COUNTY CODE,TITLE2,CHAPT20 ER2SECTIONS 2.20.100THR000H 220.14000NCERNINGWM [ILI[1[hLI(-il.l, n%i3.!�LI
Lendefs Name HAZARODUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SQD. V
Lendefs Address ? f A
PNNpp pp AaDIR
12207
o� I certify that I have read this application and state that the above RC.FEE PERMIT FEE
information is correct. I agree to comply with all county h
ordinances and State laws relay to building construction,and (J
6. hereby authorize Iepresen of this County to enter upon ISSUANCE FEE py
the above-mentioned pro r inspection pur Gass.
d
INVESTIGATION FEE TOTAL FEE
sp,w„eor Aopiw°w.�ym aro /
SEE REVERSE FOR EXPLANATORY LANGUAGE.