HomeMy Public PortalAbout10314 LIVE OAK AVE_Building__ aMUCA7MM FOR BMLDNM [PERMN �
COUNTY OF LOS ANGELES BUILDING ARID SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL BUILDIN9 ADDRESS
SS, /O
I hereby affirm that I have a certificate of consent to self Insure, BUILDINDDREL
or a certificate of Workers'Compensation Insurance,or a certified .1 azlgL
copy thereof(Sac 3800,Lab C) ZIP
Policy No Company LOCALITY
SI OF L NO OF BLD OW ON LOT
ElCertified copy is hereby furnished dQ NEAREST CROSS ST
❑'Certified copy Is filed with the county building Inspection TRACT BLOCK LOT NO
USE ZONE MAP NO
department 2
ASSESSOR MAP BOOK J PAOGE/
Date APA�EL SPECIAL CONDITIONS
pplicant
CERTIFICATE OF EXEMPTION FROM WORKERS' wNE
COMPENSATION INSURANCE / � WITHIN 1000 FT OF SCHOOL? YES NO
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) CI ZIP /
I Certify that in the performance of the work for which this permit
Is Issued, I shall not employ any person in any manner so as to AF 3INEER TEL NO 4
become subbje�ct to the Workers'Compensate STATISTICAL CLASSIFICATION APT CONDO
nJZ
Datj2V2 V Applicant `A l �r.�, ,I ADDRESS CLASS NO DWELL UNITS
NOTICE TO APPLICANT- If, after making this Certificate OfCONTRACTOR TEL NO REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' SETBACK YARD HWY PROPLINE 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 DECLARATION CITY LIC CLASS FIDE c
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SO FT SIZE NO OF STORES NO OF FAMILIES
Professions Code,and my license Is In full force and effect NEW ❑ BK _ PG D 0
License Number LIC Class TI OF ADD ❑ VALUATION W
a
Contractor Date ALTER ❑ $ Z
❑ I am exempt under Sec -
REPAIR ❑
B&PC for this reason DEMOL ❑
Date. USE OF TING URM ❑ LDMA P/C# qq
Signature P I NT(P T) LDMA Perm# 1
❑ I, as owner of the property, or my employees with wages as R Or, . a a
s
their sole compensation, will do the work and the structure is
not Intended or offered for sale (Section 7044, Business and FINAL DATE Q1;I��
Professions Code) G `•`_' "10.
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE AHAZARDOUS MATERIAL /
❑ I, as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN ITEMS"
Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL Y
licensed contractors to construct the project (Section 7044,
Business and Professions Code.) YES❑ NO❑ 113TAL 70 - 343
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING CHECK ("�
CONSTRUCTION LENDING AGENCY COAST
OCCUPANT
QUALITY REQUIRE AMANAGEMENT DPERMIT FOR ISTRICT(SCAOMDN OR )SEECPERMITTIN6 CHECATION KLIST
' 1 e J t
FOR GUIDELINES CHECK a 01
I hereby affirm that there is a construction lending agency for vEs F-1 No 1:1 •w {,�i__C
the performance of the work for which this permit Is Issued(Sec le
I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD / CHANGE CO
3097,CIV C) PERMITTING CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES '
COUNTY CODE,TITLE Z CHAPTER 2 2D SECTIONS 2 2D 100 THROUGH 2 20140 CONCERNING
Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAGMD
a
Lender's Address OWRERORAGENT 1IO1IO-13LI If 9f 133 PCI
0 1 certify that I have read this application and state that the above 2c s
r•Ar,S2 Information is correct. I agree to comply with all county PC FEE PERMIT FEE �� .4,35 l• 1 9:4i
ZZG ordinances and State laws relating to building construction,and
hereby authorize repre3e atives of this County to enter upon ISSUANCE FEE
hove rile 'one ope ty for nspection pu ses
a INVESTIGATION FEE TOTAL FEE
1 SEE REVERSE FOR EXPLANATORY LANGUAGE 4