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Home My Public Portal About10781 DAINESWOOD DR_Building__ COUNTY OF LOS ANGELES j BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESS O [j Q.w no2� R I hereby affirm that I have a certificate of consent to self insure, I O� S , or a certificate of Workers' Compensation Insurance,or a certified .,J I copy thereof(Sec.3800, Lab.C.) P;)� ZIP Policy No. Company I 91 7 SO LOCAUTV ZE OF LOTT�_• I NO.OF LDGS.NOW ON LOT Q$ copy is hereby furnished. uu6� [ Jai Ce 71.. fQ- ❑ Certified CO 1W/ NEAREST CROSS /SGC/ ,IiPCU[/ ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. Of department. USE ZONE P NO. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' E NO. owNEq - - COMPENSATION INSURANCE Vf.J SzM }"�^ gJ�j�J4$-72�/Z: WITHIN 1000 FT.OF SCHOOL? YES N k. (This section need not be completed if the permit is for one hundred AD �� t 'DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED By dollars (S 100)or less.) CRV ZIP I certify that in the performance of the work for which this permit I ei /e C 1 T �I7$O is issued, I Shall not employ any person in any manner SO as to ARCHITECT OR ENGINEER TEL NO. v Df become subject to the Workers .Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date1 �a' t.?Applicant `.l�1(_ yQ— ADDRESS CLASS NO. � DWELL UNITS 11/ ' NOTICE1 TO APPLICANT. If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you-'should become sUbject to the Workers' CONTRA t LjJO., _O�Zy SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith W Al _1so.J /1IIIi`� FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC,NO. P L LICENSED CONTRACTORS DECLARATIONyltr (CX4?OSS SIDE CITY LLASS IC.CP L I hereby affirm that -I am licensed underprovisions of Chapter 9 'I'L'L-�I W J` CC-Z9 aD�3N�' (commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORIES NO,OF FAMIUES SEWER MAP Professions Code,and my license is in full force and effector r. - NEW ❑ BK PG d License Number O � Lin.Class C-Sq XM E'1a DESTION OF WORK ADD "p VALUATION D Q Contractor Date 3' I q_ f 3 a t� ALTER C1 $ ZLI [ W Elam exempt under Sec. 1 - iN611F,REPAIR ❑ $ �O B.SP.C. fort ' reason ' �i DEMOL _❑ W LDMA P/C x Dale:. —iS-�1`3 E of IsnNG BLDG. URM ❑ a Signature APPLICANT(PRINT TEL N '-. =COMA Perm x - - ' "' Ar.( y Z ..... _. ... 111 ❑ I, as owner of the property, or my employees with wages as lila T- Sb 8 3�D S-Z`� Z T.r their sole compensation, will do the work and the.structure is ADDRESS - - "'-- - _0 '730 117.90 not intended or Offered for sale (Section 7044, Business and ( LD L..L ON NY- Ul C_ FINAL DATE /y�, Q Professions Code.) WILL THE AEFUCANT OR FUTURE BULLRING OCCUPANT HANDLE A HAZARDOUS MATERIAL V 1 ITEM_ ORA NTS SPE COMAIN M A HAZARDOUS MATERIAL EQUAL RI OR GUIDE?GREATER THAN THE TOTAL 117. 90 ❑ 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE MAZARWUS MATERIALS INFORMATION GVIOE? FINAL BY licensed COOhactOrS f0 COnefrUCf the project (Section,7044, YES NOF}- Business and Professions Code.) CHECK 11/.9G WILL ME INTENDED USE OF THE BUIDUNG BY THE APPUCANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH C CONSTRUCTION LENDING AGENCY COAST AIR OUALTY MANAGEMENT DSTRICT ISCAQMDI SEE PERMITTING CHECKUST FOR J�10I E �.-y' 7- 3 t:HAMtiE ,00 GUIDEUNES. - - I hereby affirm that there is a construction lending agency for YES El Nok H the performance of the work for which this permit is issued(Sec. pi [HAVE READ THE HAZARWUSMATERIALS INFORMATION GUIDE AND THE SCAOMDPERMnTING ��- �� J�19�9 3097,Civ.C.) CHECKLIST I UNDERSTAND MY REOUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. ) j w TITLE 2,CHAPTER 2"+0 SECTIONS 2.20.100 THROUGH 2.20.I40 CONCERNING HAZARDOUS o Lender's Name M9TE LS R P IG AND FOR OBTAINING A PERMIT FROM THE SCAOMD. ..,_ ... __. ...._,. ... 2,7�0 1 AM 3:35 o Lender's Address V11 Q— � b I certify that I have read this application and state under penalty 0 of perjury that the above information is correct.I agree to comply PC.FEE PERMIT FEE eq with all county ordinances and State laws relating to building m construction, and hereby authorize representatives of this County ISSUANCE FEE �� ato enter upon the above-mentioned property for inspection purposes. INVESTIGATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE APPUCAMON 'FORBULL IG PER uIt5); g COUNTY OF LOS ANGELES BUILDING AND SAFET i WORKER'S COMPENSATION DECLARATION FOR"APPLICANT TO FILL IN BUILDING ADDRESS 1 - - SUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, _ or'a certificate of Workers' Compensation Insurance,or a certified • �/ ' 1 '� "'t r- 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 GROSS,ST.••, - El Certified copy is filed with the county building inspection LOCK TRACT - B - LOT NO. d - V ' - department. .. US ZONE MAP NO. - • Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS 11 OWNER TEL,NO, - - CERTIFICATE OF EXEMPTION FROM WORKERS' - COMPENSATION INSURANCE ` t A - /r WITHIN 1000 FT OF SCHOOL? YES NOF (This section need not be completed if the ADDRESS p permit is for one hundredpISTRICi GROUP TYPE CONSL FIRE ZONE PROCLSSED BY dollars 1$t00) or less.) - - ` ~` / ` 1 ,i - CITY - ZIP ' i I certify that in the performance of the work for which this permit is issued I Shall not employ any person at any manner so as to become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO. - �STATISTICAL CLASSIFICATION APT ' CONDO , Date i ,r I r :Applicant ADDRESS ' CLASS NO. -/ ' DWELL UNITS , I t NOTICE TO APPLICANT. If, after,.making this Certificate: of - REQUIRED _ TOTAL_SETBACK FROM -EXIST Exemption, -you shouldbecome: Subject t0 the Workers - CONTRACTO - TELLNCI C- '-., 'SETBACK- 'YARD _77'HWV y PROP LINE ' - WIDTH ' ' Compansation proviaon5 ,Wthe Labor Code, you must forthwith �,n 1 -J .'�' r• FRONT - comply with such provisions Or this permit shall be oeemea revoked. ADDRESS LIC,NO. P L LICENSED CONTRACTORS DECLARATION "z�' SIDE CITY' UC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 r - - - f '�' SEWER MAP } (commencing with Section 7000)of Division 3 Of the Business and SQ.FT SIZE NO.OF STORIES NO.OF FAMILIES - a Professions Code,and my license isin lull force and effect. NEW ❑ BK PG •� License Number 1 - Lic.Class • DESCRIPTION OF WORK , / ADD •l,ti El- VALUATION - LU Contractor 21' _ Date ,i , ALTER 1 i'❑ $ El.I'am exempt under Sec. ~ `-'1 ` ' " . - ` •REPAIR ❑ $ I> • - 8&PC for.this reason ,j;/. 7 - DEMOL .❑ -< LOMA P/C p Date -' ! - 7 USE OF EXISTING BLDG. URM ❑ e 1 a -'r. Signature. - '' APPLICANT(MINT) TEL NO. L OMA Perm a 411 t ❑ I as owner of the property, or my employees with wages as f •• S t .{ !ti r i 1 k - Z I i4 Ui their sole compensation, will'do the work.and the structure Is ADDRESS - °$ not intended or offered for Sale (Section 7044, Business and • I • ,. •I 't !_ f e FINAL DATE Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J 'ORA MIXTURE CONTAINING A HAZARDOUS MATERIAL INFORMATION TO OR GREATER THAN THE ,�, � y f s9M.Q ❑ I, a5 owner Of the property, am eXCWSivey contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIOEi FINAL BY - > I 1 4 + Blicensed es contractors to construct the project (Section 7044, FFll YES❑ NO�?. Business and Professions Code.) I ' y' - WILL THE INTENDED USE MI THE CONSTRUCTION BY THE APPLICANT OR FROM BUILDING SOUTH , OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR EE PERMITTING FROM THE SOUTH i 1 CONSTRUCTION LENDING AGENCY °oEUHIEs upury MprvpcEMErvr DlsrRlcr Iscpamm SEE PERMnnruc cHEcxusT FOR " - f) °h .7� �, YES❑ I hereby affirm that there is a construction lending agency for rvo [Q the performance of the.work for which this permit is issued(Sec. /1 w 3097,Civ.Q I HAVE READ THE HAZARDOUSMATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING !I• -I�u 9,_fiIIJUI t 1, Jay, CHECKUST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. , / ` •`it TITLE 2.CHAPTER 2.20 SECTIONS 220.100 THROUGH 2.20.140 CONCERNING HAZARDOUS_i .,4 , Lender S Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMO. 1 i TAM 0 Lender's Address o arvrvoX N,.c rl g Icertify that I have read this application and state under penalty O of,perjury that the above information is correct.I agree to comply P.G.FEE PERMIT FEE o With all county ordinances and State laws relating to building am construction, and hereby authorize representatives of this County ISSUANCE FEE to enter upon the above-mentioned property for inspection purposes. INVESTIGATION FEE _ TOTAL FEE t - ^ SEE REVERSE FOR EXPLANATORY LANGUAGE !�