HomeMy Public PortalAbout10816 DAINES DR_Building__ COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT T FILL IN BUILDING AD ESS •-
BUILDINGAD6� I ^f�C O GrNLS 2.
I hereby affirm that I have a certificate of consent to self insure, /
>� or a certificate of Workers'Compensation Insurance,or a certified
1 cepy thereof(Sec.3800,Lab. .) CITY ZIP G{ l , G
Policy No. Company� '�� e c-, (c--- , I(� � v LOCALITY
SIZE OF LOT N .0 BLDGS.NOW ON LOT
qx-rtifietl copy is hereby furnished. NEAREST CROSS ST.
Certified copy is filed with. the county building spection TRACT BLOCK LOT NO. -
dap m¢yr.' U5 NE MAPITI
•� Date ``-1t Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS 7 .
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ' ( NNl / !EL.NO. _%Z�,/ YES No
COMPENSATION INSURANCE (� 7 ADDRESS WITHIN 1000 FT OFSCHOOL4
( (This section need not be completed if the permit is for one hundred Q�� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($
hat)i or less.) - CITY // /�' .ZIP
I certity that in the performance of the work for which this permit �- '^^ (C_ l [ ���U �O ,G(.°G-elm
IS issued, I Shall no employ,any On in any manner so as t0 ARCHITECT OR UNURNEER TEL.NO.
become subject the��W)Orke ' om nsatl/0p/LJgWS. STATISTICAL CLASSIFICATION APT CONDO
Dale ppllcan �DDRESS CLASS NO. C2?-1 DWELL UNITS /
NOTICE O A PLICANT, If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
CONTRACTOR EL. O
�Ezemption, you Should become subject f0 the WQlka(S' /, � SETBACK 1 YARD HWY PROP LINE WIDTH
,_Compensation provisions of the Labor Code, you must forthwith Np Q� FRONT
;omply with such provisions or this permit shall be deemed revoked. ADDRESS G.� _y PL
6 FU, �r �S G 3J Fs SIDE
LICENSED CONTRACTORS DECLARATION -clTv uc.cuss p L o
�j
I hereby affirm that I am licensed under provisions of Chapter 9 - Co L/t 7 SEWER MAP 'T V
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORES NO.OF FAMILIES NEW ❑ BK PG "1-'i '8
T
Professions Code,and my license is in full force and effect. 1 - _ V
C1 ZD DESCRIPIOLJOF WORK Cr �� VALUATION -- D ^,j�I? 82 O;0
F` i; iJie 1-
License'Num r Lic.Class -�' t ADD ❑ 1 tL
Contractor ate U ALTER ❑ $ U I f iTEl�3 Z
❑ I am exempt under Sec. REPAIR $- - ti TI i T AL 82 - 00
8.8P.C.for this reason CC"I1 0 L)-t woo DEMOL ❑ CHECIKI !22.00?
USE OF ISTING BLLOMA P/C p
Date: C — IV - PRM ❑ CHANGE
Signature APPLII" "v ..LDMA PermN - .
❑ 1, as owner of the property, or my employees with wages as Al�[•i VV OfVV q - p
their sole compensation, will do the workand the structure.is ADDe f IM10-000 y ')LJ Ltd I9 }
R SS /�)
not intended or offered for sale (Section 7044, Business and 6 `- • Cl-If V 7 uFINAL DATE Q e�
Professions Code.) O 30124 1 A1i1v.L1,c,
.WILLTHEAPPLICANTODUTUREBUIWINGOCCUMNTIWNDLEAHAZAROOUe MATMIAL ✓ ,/ J
❑ 1, as Owner Of theproperty, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN
Y g THE AMOUNT PE IED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINALB j
licensed contractors t0 construct the project.(Section 7044, TEs❑ NO
IN AA
Business and Professions Code.) ,
WILL TME INT DEO UBE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
OCCUMNTR UIREAPERMITFOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
--CONSTRUCTION LENDING AGENCY coasr AIR ALITY MANAGEMENT DISTRICT ISCAOMDI BEE PERMITTING CHECKLIST
FORGUIDELINESXE�.ELIT
I hereby affirm that there is a construction lending agency for YEs❑ N
the performanceof the work for which this permit is issued(Sec. I HAVE RMDRDOUR MATERIALS INFORMATION GUIDE AND THE SCAOMD `
3097.CIV.C.). PERMITTING UNDFABTANO MY REQUIREMENTS UNDER THE LOS ANGELES
� COUNTY CODHAmEfl t20SECTION52ffiWRTHPOUGH 2a).t�O CONCERNING
3 LentlBf3 Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THESCAOMD.
Lender's Address -
o I certify that I have read this application and state that the above P.C. EE PERMIT FEE
information is correct. I agree to comply with all county .
ordinances and State laws relating to building construction,and !G
g. e t authorize representatives of this County to enter upon ISSUANCE FEE - A5
7� the ova-1/nf/�pned property( inspection n purpo /V ✓f ��
/q0 INVESTIGATION FEE TOTAL FEE
arowwno,Nn, � ��
SEE REVERSE FOR EXPLANATORY LANGUAGE. -