HomeMy Public PortalAbout4912 DOREEN AVE_Building__ _ COUNTY-OFLOS AN.G_FCES „ BUILDING AND SAFETY,
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUIL INC ADDRESS
or hereby affirm that P BUILDING ADDRESS
have a certificate of consent to self insure,
or a:certificate of Workers' Compensation Insurance, or a certified
'copy thereof(Sec. 3800, Lab,C.) %CITY
,ZIP E7/L, 9�7 D-s"1
6 U LOCALITY
Policy NO. Company SIZE OF LOT' NO.OF BLDGS.NOW 0 LOT
❑ Certified copy is hereby furnished. - - NEAREST CROSS ST. '
❑ Certified copy is filed with.the county building inspection TRACT BLOCK LOT NO.
department, I ' USE ZONE MAP N0.
Date Applicant ASSESSOR MAP BOOK PACE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF COMPENSATIONION FROM INSURANCE WORKERS' OWNER S TEL
)��d WITHIN 1000 FF OF SCHOOL' YES - rvo .
(This Section Readout be completed if the Permit is for one hundred ADDRESS -
dollars($100) Or Jess.) G.; DISTRICT GROUP Y ON T FIRE ZONE PROCESSED BY
CITY ZIP q
I certify that in the performance of the work for which this permit 7gx C/7y 64 91 g'O _ �Q f e_3 — �!
is issued, I shall not employ.any person in any manner so as t0 ARCHITECT OR ENGINEE TEL NO. '
become subject to the lWorkers'Compensation Laws. - STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS - CLASS N0. 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 NO5, SET BACK YARD HWV PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith
with.such provisions or this permit shall be deemed revoked. FRONT
comply Y P P ADDRESS LIC.NO. p L
LICENSED CONTRACTORS DECLARATIONSIDE -
CITY LIC.CLASS P L
I.hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and so,FT SIZE NO,OF STORIES NO.OF FAMILIES -
NEW ❑ BK PG
Professions Code,and my license is in full force and effect. D }
DE RIPTION OF VALUAT d
License Number Lia Class ADD, D.
'Contractor WORK Date - &/ ALTER ❑1 $
It
❑ l am exempt under Sec. I'� -REPAIR-- ❑' $ Q
B&P.C. for this reason EMOL -❑1 W
LDMA P/C'A
Date: _ SE OF EXISTING BLDG. " URM ❑
Signature
APPLICANT
APPLICANT(PRINT) TEL NO. LDMA Perm A Z
I, as owner of the property, or my employees with wages as _ Z f a
. t OIL sole compensation; will do the work and the structure is ADDRESS _ O
' not intended or offered for sale (Section 7044, Business and FINAL DATE
Professions Code.) - L WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL- '2 •'7 ¢a
f`'
Lrr
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE M } CI
El I, as owner of property, am exclusively Contracting wltlT
licensed contractors to construct the AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
'project (Section 7044,. YES 11NO❑
Business and Professions Code.)- .
. - WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING ) t"
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH L" C p O CHI. i115
CONSTRUCTION LENDING AGENCY GOIDETUNES�BAUTY MANAGEMENT DISTRICT SCADMD SEE PERMITTING CHEGKUST.FORi1,4
1 hereby affirm that there is a construction lending agency for YES El NOD ,. - .Tlt�l!�f]� IIE_
a' the'performance of the work for which this permit is issued(Sec. -
p1 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ,
3097,Ov. Ci.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, (` __.
w TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS I�IEr�I—llj i_I_ "i>rA'�1!%',
L20dE15 Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
.1
o Lender's Address - - 1+_IJ+' • 1 All r'e_�_
o owxea oa acem -
o. I certify.that I have read this application and state'under penalty
o
w of perjury that the above information is correct I agree to comply PC.FEE PERMIT FEE
with all county ordinances and State laws relating to 'building
ro Construction, and hereby authorize representatives of this County ISSUANCE FEE
to nt up n the above-mento Ic�.PFoparty for inspecti0 Aur uses. -
n r• // INVESTIGATION FEE TOTAL FEE
of of o axm Oers I/
SEE REVERSE FOR EXPLANATORY LANGUAGE -