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Home My Public Portal About5544 EL MONTE AVE_Building__ QPFUMMOM GOO R BUMONG PER N ff i1 COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION ESS FOR APPLICANT TO FILL IN BUILDING apo BIjILDINGADD I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or a certified �s� AJ' 06 1 ow-1/lz- //l/�' CZIP o/��y thereof(Sec.3800,Lab.C.) LOCALITYPolicny o�//•2 7 S 3 2 Com an /y�T L�/�7Ji(J hCITY I7 6/-C Z-T 7/7�Q P Y SIZE OF LOT 'NO.OF BLDGS.NOW ON LOT ❑ Certified Copy is hereby furnished. " '� NEAREST CROSS ST. A Certified co is filed with the count buil in inspection TRACT BLOCK LOT NO. - isl PY Y g P 9 L USE ZONE MAP/NO department.` ��3 �3 ASSESSOR MAf BOOK PAGE PARCEL n Da '2_24 Applicant gs 7 o �:/ SPECIALCONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER I TEL.NO. YES NO COMPENSATION INSURANCE "" ` ` WITHIN 1000 FT.OF SCHOOL? ADDRESS (This section need not be completed if the permit is for one hundred DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) clTr A t/ ZIP / I certify that in the performance of the work for which this permit � E/`?/L� cZT is Issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO. become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. 'Al DWELL UNITS NOTICE TO APPLICANT: If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST ' _ - Exemption, you ShOUId become subject t0 the Workers' CONTRACTORTEL.NO.` SETBACK YARD HWY PROLINE WIDTH Compensation provisions of the Labor Code, you must forthwith �/ v .71" Q`�� FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. I_(:Y S PY P P PIL H _I os ' ^� LICENSED.CONTRACTORS DECLARATION CITY ' LIC CLASS SIDE �`�a)J( a>>k-o I hereby affirm that I am licensed under provisions of Chapter 9 - SEWER MAP 1 ITEMS C1 (commencing with Section 7000)of Division 3 of the Business and SQ.Fr.SIZE NO.OF STORES NO.OF FAMILIES NEW ❑ BK PG 0 Professions Code,and my license is in full force and effect. D TOTAL. 6-7 � 3?� [, DE CRIPTION OF WORK ADD ❑ License Nu r; s LiC Class VALUATION CHECK HEC Contractor Date ALTER $ REPAIR E] _ `:ts{��i3E; a — ❑ I am exempt under Sec. / B.BP.C.for this reasonG� cs ODEMO L ❑ USE OF EXISTING BLDG. LDMA P/C# 00010-I�j1031 10f 2/90 Date: URM. ❑ i Signature APPLICANT(PRI T TELrm NO 7 LDMA Pe # -,flu f 1 Al kI i t0 35 ❑ I, as owner of the property, or my employees with wages as O C �Lf �� J their sole compensation,will do the work and the structure is AD ES L T' not intended or offered for sale (Section 7044, Business and /v, �/� af� S/ FINAL D` � Professions Code.) C WILL THE APPLICANT OR FUTURE BUILDING OCCUPANTHANDLE A HAZARDOUS MATERIAL j- ❑ 1, as owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN P P Y Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project.(Section 7044, YES❑ NO❑ Business and Professions Code.) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. hereby affirm that there is a construction lending agency for YES❑ NO❑ the performance of the work for which this permit is issued(Sec. G.•1 CD 3097,CIV.C.J. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD' PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES m. COUNTY CODE,TITLE2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING r,M} r_t r•"} �•j, "`.I '—'I ' al; Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. It- a Lender's Address wmmonAGENT r_1 rrI MI6 o I certify that I have read this application and state that the above ' M information is correct. I agree to comply with all county P.C.FEE PERMIT FEE �� / t-� 3 ordinances and State laws relating to building construction,and �j a. hereby authorize representatives of this County to enter upon ISSUANCE FEE the above en Ion �/ ro or inspection purposes. INVESTIGATION FEE TOTAL FEE / A (ji ✓ sq„emro�«mem ow SEE REVERSE FOR EXPLANATORY LAN66AGE Cr` CA ('111