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HomeMy Public PortalAbout9194 JAYLEE DR_Building_10/6/1993_add 2 car garage ADPL, C AMON FOR C MOS ONG PERNT COUNTY.OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR'APPLICANT TO FILL IN BUILDING DDRESS I hereby affirm that I have a certificate of consentto self insure, BUILDING ADDRESS (� �[ j[� or a certificate of Workers' Compensation Insurance,or a certified i i qI!'r F-- J q(�/ LiF C ID R Copy thereof(Sec.3800,Lab.C.). CITY.,�E ��r ' C rY Z�P/�/7gO LOCALITY Policy No: Company 1.• (� SIZE OF LCT NO.OF BLDGS.yOW ON LOT ❑ Certified Copy is hereby furnished. SOO© ,S�}'( dL NEAREST CROS T. ❑ Certified copy is filed with the'county building inspection TRACT BLOCK D LOT NO. USE ZONE MAP NO. department. Date Applicant ASSESSOR MAP BOOK PAGE _ PARCEL +'] �q S�g 01,6 Q 2 7 SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERStV OWNER , ppm L COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? ves No (This section need not be completed if the permit is for one hundr A DRESS y ,f (� AVE dollars ($100)or less.) JOZ G. A R DEJRD A LE DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY I certify that in the performance of the work for hich this per CI�^ M 6 A B Q I E(_ ZIP c117 c ��� is issued, I shall not employ any person.in any anner so } " J JC become SU JeCt to the WOrkerS'COmpen ti0 a S. ARCHITECT OR ENGINEER STATISTICAL"CLASSIFICATION APT CONDO Date��Applicanb ADDRESSCLASS NO. ssLL— DWELL UNITS NOTICE TO APPLICANT.' If, afterIng this Certificate of 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 FRONT comply with such provisions or this permit shall be deemed revoked. 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 SQ.FT.SIZE NO.OF STORIES NO,OF FAMILIES a Professions Code,and my license is in full force and effect. NEW ❑ BK PG D U License Number Lic. Class DESCRIPTION OF WOR `� ADD (� VALUATION Contractor Date 2`,, A F2 G A I2 A4 o.oo , .� ALTER o:, S Skott 4 I� TR L REPAIR 13o $ ElI am exempt under Sec. � (� ((( T i`l9 CH ` B.&P.C.for this reason '19 \, U PLA-M `� F.e�JJ DEMOL ❑ LDMA P/C"# I1 Date: USE QF'ViSTING BLDG �/� UR ❑ to Signature Ul v (LAC �0' D�.>— 'nQ Z APP (CANT(PRINT) TSL POO.�� `D LDMA Perm# -- ,-r '� IL B psH A- A m�E 4 4 a . ❑ I, as owner of the property, or my employees with wages as Z their sole compensation, will do the work and the structure is ADDRESS /� f� Qn n O '?_+t]L; tif, )_ not intended or offered for sale (Section 7044, Business and o E -A RDE ND ALE AVE SANG f9B RJEL, FINAL DATE Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL (J lY \ - -- - OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ` M ❑,I, as owner of the property, am exclusively contracting with Q AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY j• •3 0'3 licensed contractors to construct the project (Section 7044, YES❑ No I� --- Business and Professions Code.) _ � ��r�•_, 4�'-`.,3.t' WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING - -- --- -- CUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _ j,Ty�+iy� CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR -: i �:I•. GUIDELINES. �/� I hereby affirm that there is a construction lending agency for YES❑ No ltd Tj I i HL `_ a60 w the performance of the work for which this permit is issued(Sec. ° 3097,CIV.C.) I HAVE READ THE HAZARDOUS MAT I SINFORMATIO IDE AND THE SCAOMD PERMITTING t -i{ w..�.�r N CHECKLIST.I UNDERSTAND MY R QUI EMENTS UND HE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 2.2 CT 2.2 .100 THRO 2.20.140 CONCERNING HAZARDOUS _,hf„••� ��I, Lenders Name MATERIALS REPORT IN E THE SCAQMD. d o Lender's Address O OWNER OR AGENT o I certify that I have read this application and state under penalty of perjury that the above informs n correct.(agree to comply P.C.FEE D I PERMIT FEE ^ 7o with all county inances an Stateis laws relating to building d( < constructio •a d h eby author a representatives of this County ISSUANCE FEE / I/ �_I 1<< 1 AIN 9 to enter on h ab ve-mentio d property for ins/pect)io�n�urp/QQses. �(p• 7" y!��'/�;�[ �j� ?/,t'•I INVESTIGATION FEE TOTAL FEE // V/ 5ip,ulu W Date SEE REVERSE FOR EXPLANATORY LANGUAGE