HomeMy Public PortalAbout9845 DAINES DR_Building__ t APPLICATIONFOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS "
r BULDING ADDRE
I hereby affirm that I have a certificate of consent to self Insure,
or a certificate of Workers' Compensation Insurance,or a certified• f eq-s
bL
copy thereof (Sec 3800,Lab C) CITY, - ZIP /n�^
CA +/ L/ LOCALITY
Policy NO Company SIZE/OF"LOT NO OF BLP.QS NOW ON LOT
❑ Certified copy is hereby furnished �001UD ONE-
NEAREST CROSS ST
❑ Certified copy Is filed with the county budding inspection TRAC BLOCK LOT NO /O
department (P USE ZONE - MAP NO
PAGE_ PSSOR MAP'BQDate Applicant ASSE
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM'WORKERS' OWNE ELN
COMPENSATION II NSURANCE �� -30 WITHIN 1000 FT OF SCHOOLS NO
(This section need not be completed If the permit Is for one hundred ADDRES oA
�1-✓J DISTRICT GROUP T ON IRE NE PROCESSED BY
dollar§,($100) or less) - • •
I certify that In the performance of the,work for which this permit CIT /J� C-f� ZIP
is issued, I shall not employ any person in any manner so as to, I!O
become subject to the Workers'Compensation Laws ARCHITECT OR ENGINEER TEL,NO
1 P STATISTICAL CIL
2BSS/IFKATION APT CONDO
•
Date.L. Applicant, ADDRESS 'CLASDWELL UNITS
NOTICE TO APPLICANT If, after making this Certificate 'of 1 REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become,' subject to the Workers' CONTRACTOR TEL NO SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked' FRONT `
P Y P P ADDRESS LIC NO P L
LICENSED CONTRACTORS DECLARATION PILE
CITY LIC CLASS PL
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Busmess 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
DES RIPTION F WORK VALUATION
License Number Le Class �F S _lj �� � •6� ADD ❑ /�
Contractor Date 71 ALTER ❑ � ,v
`I ❑ I am exempt under Sec REPAIR ❑
I B&PC for this reason DEMOL ❑ V
y • LDMA P/C# W
Date USE OF EXISTING BLDG URM ❑ 1
SignatureAPPLICANT(PRINT) TEL NO LDMA Perm#- ril •{=T Z
-7 7
/{�� I, as owner of the property, or my employees with wages as 0 �� _ 103.[[
/ their sole compensation, will do the work and the structure Is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DATE Q I ITEM'-:
Professions Code) J
' WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL Z
DR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO ORGREATERTHAN THE -' TOTAL 1 b3 05
❑ I, as owner of the property; am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAIAX��_
licensed contractors to construct the project (Section 7044, r 1013.
Business and Professions Code) ves❑ No❑ {EL•P (E i
WILL THE INTENDED USE OF THE BUIDLING BY THE'APPLICANT OR FUTURE BUILDING ,�,�••�� {_E IIS I
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH u
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 ves❑ No❑
a the performance of the work for which this permit Is issued(Sec I'I�III]-L] 1
IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING _
3097, CIV C) - CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES,COUNTY.CODE
TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS _ �6( 3 - f AM I 1 o jfT
3 Lender's Name - MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD _
o Lender's Address '
O ONNER OR AGENT '
o I•certify that 1-have read this application and state under penalty
O of perjury,that the above Information Is correct I agree to comply PC FEE PERMIT FEE
o with all county ordinances and State laws relating to budding C/v
co construction, and hereby authorize representatives of this County ISSUANCE FEE
Cl)
t nt po(1 th abo -menti s
,� � Jpection ur oses (p j•YJ
X7 993 INVE ATION FEE TOTAL FEE "ooV D
^ iwa a roowan 7mfas
SEE REVERSE FOR EXPLANATORY LANGUAGE