Loading...
HomeMy Public PortalAbout4908 DOREEN AVE_Building__ II ' WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self ypy �Iff1 �L( �'11 �OlPdli" I}�R WRONG PERFtg "T insure, or a certificate of Workers' Compensation Insurance, lrllll Il LSV- ll Il V 11 ��l UV1 LTJ 11 V U LS II\111 T711 or a certified copy thereof (Sec 3800, Lab. C) - - COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. - Company- - BUILDING, r a ��, `'J -�� ElCertifiedcopy is hereby furnished. .. FOR APPLICANT TO,FILL IN ADDRESS Y /NV ❑ Certified copy is filed with the county building inspeo- BUILDING 0p L tion,deportment. ADDRESS OO 7l4' Date - Applicant' + CITU' ZIP LOCALITY NO. OF BLDGS. NEAREST • - CERTIFICATE OF EXEMPTION FROM WORKERS'. SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE - _ _ _ ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP e00K PAGE PARCEL hundred dollars ($100) or less.) TEL. �p/�'r OWNER - NO. "q-2(ZO USE ZONE MAP NO. I..certify that in the,performance of the work for which this SPECIAL > permit is issued, I shall not employ any person in any manner ADDRESS oyeo� CONDITIONS R so as to become subject to the Workers' Compensation Laws. O CITY ZIP - Date Appl icon f - ARCH9kQT OR TEL. - ENGINEER DISTRICT GROUP TYPE 'FIRE - PR SBED BY NOTICE TO APPLICANT: If, after.making this Certificate of ' ' CONST ZONE Exemption,. you-should become subject to the Workers Compensation provisions of the Labor Code, you must forth- ADDRESS - r'vD E� with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CO DO. deemed revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATIONLI CL45S NO.�DwELL. UNITS— I hereby affirm that I am licensed under provisions of Chapter 9 AD 55 NO' SEWER MAP ' (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS BK VALIDATION SQ. FT NO. OF NO. OF CHECK License Number' Lia. Class SIZE STORIES FAMILIES ONE t - - El VALUATION Contractor Date DESCRIPTION OF WORK WO R�KT^ / 1p14NEW ❑ -$. qQ d J� QN tSV Ls'r ( KS ADD , O'c C/ D ❑ am exempt under Sec. ALTER ❑ - B.BP.C. for this reason A- A E_ REPAIR $ DUSE OF Date: EXISTING BLDG. S DEMOL ❑ Signature APPLICANT TEL •ZL'ZO FINAL OWNER-BUILDER.DECLARATION (PRINT) (' NO. DATE S G/2� '. I hereby affirm that'l exempt from the Contractor's License B� I/ �SL�y =1 rl Law for the followingg r reason (Section 7031.5, Business and ADDRESS FINAL' Professions Code): PRESENT —' By L: I, as owner of the property, or my employees withBUILDING ADDRESS - 63 wages as their sole compensation,will do the work and SRL - - the structure is not intended or offered for sale(Section LOCALITY .,t11r. 7044, Business and Professions Code.) MOVING- - - - TEL. U'=" CONTRACTOR❑ NO.I, as owner of the property,am exclusively contracting with licensed contractors to construct the project (Sec- ADDRESS e ' tion 7044, Business and Professions Code.) REQUIREDTOTAL SETBACK FROM" EXIST.- CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 1 hereby affirm that there is a construction lending agency for FRONT _ .the performance of the work for which this permit is issued P.1. - '0- (Sec. 3097, Civ. C.). SIDE P.A. - Lender's Name -- `- _.=7 - - S - 13 LDMA Ref. q. . . . P.C. Fee$ Permit Fee + Lender's Address - - a I certifythot I have read this application and state that'the Issuance Fee Z S LDMA P/C F 0 8 above information is correct. I agree to comply with all County Investigation Fee - ordinances and State-laws relating to building construction, Total Fee ��^ LDMA Perm. N a and hereby auth01 a representatives of this County to enter upon thea o e-m tioned property for inspection purpo S. - 2-212 - 'SEE REVERSE FOR EXPLANATORY LANGUAGE SigncAurYM A pl ant or Agent Date z ' WORKERS' COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self ////pp���� O O '/`� //(�7� �FI��Ip� FOR ORp �LP��p�I(/�� �r�f l��} �//A�� insure, or a certificate of Workers: Compensation Insurance, W�-P���y!/"ll���U V _11 ®U�l IJ���DD �0 V V`-'J' Il LS�UC/U�_� or o certified copy thereof (Sec. 3800, Lab. C.)„- - - _ .. .COUNTY OF LOS'ANGELES BUILDING AND SAFETY, - Policy No. Company El - Certified mBUILDING* py.is hereby Furnished. FOR APPLICANT TO FILL IN ADDRESS 4•qO s'• "'TD-�EE� Ave _ '❑ Certified copy is filed with the county building inspec-_ BUDDING •Ory `�6 CE I AV� TEM PLS G(VT d 17&�• tion department. ADDRESS [- 11 �+V�{�/ fV r l ! CITY' . E P(e G l \. :__;. ZIP 176 4 LOCALITY _. Dote Applicant F R NO. OF LOT _ - - NEARESL p /L I ly m A CERTIFICATE OF EXEMPTIONFROM WORKERS' SiZE OF LOT '. 'Z X I7 S NOW ON LOT" Z � CR055 S7. 1-V WL�G- COMPENSATION INSURANCE 1 - t ASSESSOR, r7 ^/� _ '(This section need not be completed if the permit is for one TRACT BLOCK � LOT N6. ./ MAP BOOK 2 PAGE.46 PARCEL hundred dollors,($100)or less.) I - ,A(`` '' /s TEL [L OWNER' -Pf AQ XA NO:ID� 4 _;J2 - USE ZONE EMAP I Certify that in the.performance of the work for which this `� y NO. X73 permit is issued, I.shall not employ any person In any manner ADDRESS D oa - - - I SPECIAL - - > CONDITIONS so as to become subject to the Workers'Compensation Laws. /� � 0 CITY: — G' ZIP O 1790 Date - Applicant - ° ARCHITECT OR TEL '^ �py .DISTRICT GROUP TYPE FIRE PROCESSED BY 1Y NOTICE TO APPLICANT: If;.after making this.Certificate "of' ENGINEER O P 'DE NO. la " CONST. ZONE . O Exemption, you should become subject to the. Workers' O�^ p G- ��, r - - O ,A� T _� p _ V 3 _ U Compensation provisions of the Labor Code, you must forth- ADDRESS S TO C- U. IY, Al/ �0 -� W 2 with com with such 'Provisions or this STATISTICAL.CLASSIFICATION -_APT. CONDO. V) p y p permit shall be - TEL Z deemed revoked. - CONTRACTOR NO. // LICENSED CONTRACTORS'DECLARATION - - LIC. . CLASS NO.-12?- DWFII UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. - (commencing with Section 7000)of Division 3 of,the'Business - LIC. SEWER MAP �_} and Professions Code,and.my license is in full force and effect. CITY CLASS BK L PG"� ')'VALIDATION f 1'.7_ $Q. IT:Q NO. OF NO. OF CHECK License Number 'Lia. Class - SIZE a 27 STORIES / FAMILIES ONE ! �.t("IN�= - - - - VALUATION �., DESCRIPTION OF WORK NEW ❑ Fr _ f6 !�� Contractor Date - p _ �yy��- �-/ $ 937t - ❑I am exempt under Sec. Add .2, bt A� 0'�' c v ( bktkAD0Yy1. "ADD LTJ - D CHH. (t r�"�""� 1 1 ❑ Iti�'t-� B.BP.C. for this reason , �'Tplf1AA� Ak-" F•1 i.�1'em&X `EHOYN ALTER •REPAIR El $ Date: USE OF EXISTING BLDG. AWh Q DEMOL ❑ SignatureAPPLICANT TEL _ . . - FINAL - OWNER-BUILDER DECLARATION (PRINT). NO. DATE 2I_G Ail '!"•" m I hereby affirm that I am exemat.frothe CoContractor's.License • - - - - - -- Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): oPRESENT,•- - - - •- - - By - - BUILDING ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work'and the structure isnot intended or offeredfor sale(Section. LOCALITY _ 7044,.Business Cod and Professions Code.) -• - MOVING - - TEL. M17j I/l'Jfv�gllll�_ ❑ - - CONTRACTOR NO. PA) I, as owner of the property, am exclusively contracting N , with licensed contractors to-construct the project,(Sec ADDRESS. A - tion 7044, Business and Professions Code.) 'Dlry ' - REQUIRED - TOTAL SETBACK FROM EXISF• 1'Q/I,N/ CONSTRUCTION LENDING AGENCY SET BACK YARD HWY. PROP..LINE WIDTHS I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). SIDE P.L; _ Lender's Nome .. _ PRef. N P C. Fee$ O Permit Fee " Lender's Address - ' aI certify that Lha"ve read this application and store that the Iswonce Fee LDMA P/C k 8 above information is correct. agree to comply with all County _ InvesBgation Fee R ordinances and State lows relating to building construction, Total Fee LDMA Perm. # - a and hereby authorize representatives of this County to enter _ _ - uponthe'above-mentioned property for inspection purposes. - - SEE REVERSE FOR E%PLANATORY•LANGUAGE Signature of Applicant or Agent • Date - " COUNTY OF LOS ANGELES,. BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION I FOR APPLICANT TO FILL IN. BUILDING ADD Ess y ILLI GADDRE55}'. -t. 1 /•A \ Q (/ I hereby affirm that I have a certificate.of consent to self insure, ' or a certificate of Workers' Compensation Insurance"inspection or a certified N '� ' - y ' v copy thereof(Sec.3800, Lab.C.) CITY - ZIP. >� '~•'p' - l _ I /� r /1 ``1l YG } �-rl 91.70 LOCAL TV Policy No,j 00^�7 y CompanySIZE O LOT NO,OF BLDGS.NOW ON LOT. . Pi ❑ Certified copy is hereby furnished. 9�CG0 -2 NEAREST CROSS . ❑ Certified copy is filed with the county buTRACT BLOCK LOT NO. USE ZONE MAP NO. tlepa_rtqm¢1(nt�. ,�- i 'Date ApPhCant Ll.T'JV-Y I.Q.P ASSESSO Ae PAGE L PARCEL2� - - / ' b/ Q A-1 SPECIAL CONDITIONS m CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL Na - dxv- el COMPENSATION INSURANCE Ti -,F7V XA-' 8/L' -2/.2o WITHIN 1000 FT OF SCHOOL? ves No (This section need not be completed If the permit is for one hundred ADD ESS - - --- - ' S DISTRICT GROUP TYPE CONST FIREZONE'. =PROCESSED BY dollars($100)or less.) _ ///� 3.• RLEiV"GfI _ CITY ZIP '(•I j y, _�'_ 1'certify that in the performance of the work for which this permitL�t�.� � eA. 9��Q/, [ is issued, I Shall not employ any person in any manner so as to J �� become Subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL 1NO. n 1 APT CONDO Ef�✓CZ-17 /KG (0/15��-lJO STATISTICAL CLASSIFICATION C, , Date Applicant ADDRESSecxe 1/ CLASS NO.� DWELL UNITS H'_v a-FT NOTICE TO APPLICANT. If, after making this Certificate �7�'V T.1 /A"�-� L✓�• /`�-��-/T��/J' REQUIRED TOTAL SETBA14Io'FROM EXIST-'' _ - Exemption, you should become subject to the Workers' CONTRACTOR C/�OlGLfI1V0 TEL NO. SET BACK - YARD HWV PROP LINE..-; : 1 WIDTH Compensation provisions of the Labor, Code,,ypu must forthwith 1/3>2R CFE �pAs G B� 8 ��S 2 7wz- FRONT - comply,with such provisions Or this,permit shall be deemed revoked. ADDRESS LIC,NO. PL LICENLICENSED CONTRACTORS DECLARATION I � t '�'$L PILE _ .�___ 71- SED CITY LIC.CLASS PL ='E,t., i.!_- li_r I hereby affirm that I am licensed underprovisions of Chapter 9 -OJE1yewo eA- /7 9. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORIES NO,OF FAMILIES - t:i"IHi'i'-.'C _i'I,.a Professions Code an 'cg is in full force a effect. .i NEW ❑ BK PG 0 DESCRIPTION OF WORK VALUATION License Nu eCa r Lic.Class ADD ® m Contractor �-.Date::? .ay _ ALTER ❑ ❑ I am exempt unde Sec. / 1r�RS REPAIR ❑ $- moi!C OD • /-� `i; B.BP.C. for this rePo w a)• .C. DE MOL ❑ LUMA/d - A P/C f. l_I_. 1„i._I USE OF EXISTING BLDG. URM ❑ _ __'- Asm1ple a<41= Signature APPLICANT(PRINT) TEL NO LOMA Perm 0 t i. F' k- _ a l.a jI.• 1 0,4.as owner of the property, r my employees with wages-as 2 �f � - - F f :. Z _ 'their sole compensation, will the Work and the structure is ADDRESS O •t j A. .T.3' rot intended Or offered for sale (Sedtiori 7044, Business and i Y r RL✓� # , R0JE711eVJ,J FINAL DATE Professions Code.) WILL THE APPLICANT OR FUTURE BUILEING OCCUPANT HANDLE A XAZARDOUS MATERIAL / ❑ 1, as Owner Of ther0 err am exclusive) contrectin With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE p p y` y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? licensed contractors to construct the project (Section 7044, FINAL BY YES❑ No❑ _ Business and Professions Code.) _ c WILL THE INTENDED USE OF THE'BUIOLING BV'TNE�APPLICANT OR FUTURE BUILDING - --�. OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION',FROM THE'SOUTH ••y J ) CONSTRUCTION LENDING AGENCY Z COAST AIR QUAUTY.MANAGEMENT DISTRICT GCAOMUI SEE PERMITTING CHECKLIST FOR GUIDELINES.t I - I hereby affirm that there is a construction lending agency for ,-YES❑ NDE] the performance of the work for which this permit is issued(Seo. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING - - •� �t * •'1 3097,QV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, ' TITLE 2 CHAPTER 2.20 SECTIONS 220.100 THROUGH 2.20.140 CONCERNING HAZARDOUS 3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. o Lender's Address " 0 .r Tl an ACEM - oI Acel.h.a.t I have read this application antl state under penalty Oat the ve infor ation is correct agree to Comply PC.FEE PERMIT FEENi unty di antes a d State aws3 �. 3mcheruthDzaentatveISSUANCE FEE tt e- e O rty for inspec6o urpose5. d • u a J4. TOTAL FE 2 2 �J O SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION, 7, ` �L hereby affirm that I have Workers' of tion Int to Ce,, p n C n ToOH 2OR p n 'n�n D�. G PIEPnnPT jlSl insure, or a certificate of Workers'Compensation Insurtlnca; ' � �L (y=� u�f �f" t`lJJ LL u� u�u or a certified copy thereof (Sec. 3800, Lab. C:) i " 1. e COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company - Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BULD ADDREISSNG O f 77, Certified copy is filed with the county building inspec- BUILDING Otion department. ADDRESS n f'� V JLOCALITY SDate Applicant CITY ZIP q ;7,f0 CROSS ST Y. CERTIFICATE OF EXEMPTION FROM WORKERS' ' / NO. OF BLDGS. ASSESSOR + COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK i PAGE t PARCEL r (This section need not be completed if the permit is for one T`' USE ZONE hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO. / l TEL U7�ry SPECIAL I certify that in the performance of the work for which this OWNER /7rt L//_I ,vYL� V NO./7/f�/-T / CONDITIONSIL permit is issued, I shall not employ any person in any manner / ) DISTRICT GROUP TYPE'- 1 FIRE PRO SSED BY O so as to become subject to the Workers'Compensation Lows. ADDRESS L./Lj'/)Q /7jt }Q�41 A '� CONST? J ZONE U CITY .p,.../1 a V ZIP // d V S•o0 y q' 3 O Date Applicant - STATISTICAL CLASSIFICATION APT. CONDO.ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this Certificbte f— qq '' // U Exemption, you should become subject to the Workers' ENGINEER p //i /—� NO. +"^1 CLA55 NO.�DWELL. UNITS_ w V ` C d Compensation provisions ofr the Labor Code, you must forth- ( H with comply with such P ADDRESS - - - SEWER MAP (/ deemed revoked. Provisions or this permit shall be //''''J�JJ / /f TEL, •ts �• / 3 0 VALIDATION ? CONTRACTOR L/YC / ( j>(� NO.S /S V BK.G. PG, LICENSED CONTRACTORS DECLARATION' s ,1 LIC. �/ d I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 7 l7SSGN H [// 0. NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and -�' a. LIC / Professions Code, and my license is in full force and effect. CITY /s/H 1.4- c t ✓ CLASS E J4f O0V .�lLO/�• 1 SQ. FT [ NO.OF '/ NO.OF - CHECK D CLicense Number 7711�� f I� Lic.Class /2� G SIZE AOl STORIES FAMILIES / r ONE Contractor n LC;v-L. Date ! — J /_O DESCRIPTION OF WORK NEW I am exempt under Sec. (,, 0 1,J. ADD ALTER E] FINA BAP.C. for this reason L.Z REPAIR ❑ DATE E]Dale: USE OF EXISTING BLDG. ' DEMOL FI B./ Signature APPLICANT TEL. OWNER-BUILDER DECLARATION PRINT NO. , / p/ I hereby affirm that I am exempt from the Contractor's License /13 S�Q -_93 Q 9,3 A Law for the following reason (Section 7031.5, Business and ADDRESS j Professions Code): .PRESENT t # ete e e a ❑ BUILDING ^'-,s e t .�• ' I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL ` 1, as owner of the property, am exclusively contracting CONTRACTOR NO. . o 73 1 84 with licensed contractors to construct the project-(Sec- �. 'tion 7044, Business and Professions Code). ADDRESS REQUIREDTOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY' SET BACK YARD HWY PROP. LIN WIDTH. D I hereby affirm that there is a construction lending agency for FRONT the performance of the,work for which this permit is issued P.I. (Sec. 3097,.Civ. C.). SIDE Lender's Name P.C. Fee$' Permit Fee Q.(O — Lender's Address r I certify that I have read this application and state that the Issuance Fee J U' above information is correct. I agree to comply with.all County Investigation Fee 7•' ' $ ordinances and State laws relating to building construction, b and hereby authorize representatives of this County to enter Total Fee e . uPon the above-mentioned property for inspection purposes. •• + / 0 // J. � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Ag?fit Date .®s _ A ( - COUNTY OF LOS;ANGELES _ - BUILDING AND SAFETY _ WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN p / / �O •� �`-' '�`��'T . hereby affirm that BUILDING ADDRESS have a certificate of consent.to self insure, C O T O �� �V� or a certificate of Workers' Compensation Insurance,or a certified O d/ copy thereof(Sec. 3800, Lab. C.) CITY-MM�- GiTY ZIP LOCALITY �f Policy No. Company SIZE OIIF`LOT 1 1 NO.OF BLDGSNOW 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 NQ Date Applicant ASSESSOR f.�('BOAK - PAG,Ff� / PARCEL OYSII's GS'�!o ln�x4- SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER" AROLD -7MU0 X h6. T L NQ, VES (� NO COMPENSATION INSURANCE y NV gid "' I WITHIN loo,FT of SCHOOL? (This section need not be completed if the permit is for one hundred• ADDRESS 908 •JNR� 1 A dollars ($100) or less.) V 1� IJ f� DISTRICT GROUP TYPE CONST, [7NE PROCESSED BY I certify that in the performance of the work for which this permit cNv �tn� GtY` ZIP Q��g-© is issued, shall not employ any person"in any manner so as to f ` O became subject t0 the Workers Compensation Laws. ARCHITECT OR ENGINEER TEL NO. STATISTICAL CL SGIFICATION APT CONDO Date Applicant ADDRESS - CLASS NC. DWELL UNITS NOTICE TO APPLICANT- If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject t0 • the Workers' CONTRACTOR TEL NO. SET SACK YARD HWY PROP LINE WIDTH Compensationprovisions of the Labor Code, you must forthwith FRONT comply with•such provisions or this permit shall be deemed revoked. ADDRESS - LIC,NO. . PL LICENSED CONTRACTORS DECLARATION SIDE CITY LIC.CLASS P L hereby affirm that am licensed un vision vi of the of Chapter 9 SEWER MAP - (commencing with Section 7000)of Division 3 of the BUSIne$S and 80.Fr.SIZE NO,OF STORIES NO.OF FAMILIES ' Professions Code, and my license is in full force and effect. NEW " ❑ SK PC - d License Number Lic"Class DE GRIPTION OF WORK ADD ❑ 1VALUATION > O Lx0 Contractor • ' Date � - ' � ALTER � 0� $ ❑ REPAIR ❑ O 'lam,exempt under Sec. U BBPC. for this reason DEMOL ❑ LDMA P/C x W Date: USE OF EXISTING Bot. URM ❑ _ d Vgnature APPLICANT(PRINT) TEL N0. LDMA Perm# Z Z as owner of the property, or my employees with wages as Z heir.sole compensation,will do the work.and the structure is ADDRESS - - O HGF I�a p intended Or offered for Sale(Section 7044, El"ine s and FINAL DATE ofessions Code.) "� �"' _ �'•''ul� WILL THE APRICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 1, as Owner Of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q 1 I ti7Q i AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 5 1 licensed contractors to construct the project (Section 7044, YES❑ No❑ + i I I I AL ` Business and Professions Code.) s WILL THE INTENDED USE OF THE BURNING BY THE APPLICANT OR FUTURE BUILDING r� OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CASH (Lf a Vlh - CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT ISCAGMDI SEE PERMITTING CHECKLIST.FOR GUIDELINES. IM1_�'. .':.� I hereby affirm that there is a construction lending agency for es❑ No❑ FI9__ •'U(u the performance Of the Work for WI11Ci1 this permit lS ISSDEd($CG HAVEREADTHE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 3097, Civ.C.) CHECKLIST I UNDERSTAND MY REOWREMENIS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 2.20SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS - -� 3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE$CAQMO. liitl-JV—LiLIi I,1, (,I -1/`�_! o Lender's Addr s - i ?4 -. A OR AGENT i AM :134 o I certify,that have read this application and state under penalty NE 0 of perjury t I the a ove information is correct.I agree to comply P.C.FEE PERMIT FEE �� - n with all c ty or ances and State laws relating to wilding - construct and h eby authorize representatives of thi Co ty ISSUANCE FEE -to enter I mentioned property for ins re po ^� O a '/ ✓ INVESTIGATION FEE TOTAL FEE O• p" ^ - sy���•e or npoi�m o• D U SEE REVERSE FOR EXPLANATORY LANGUAGE