HomeMy Public PortalAbout10636 LIVE OAK AVE_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF'LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION 'FOR APPLICANT TO FILL IN BUILDING'ADDRESS
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS - ��o�✓ `� - �'�
or a certificate of Workers' Compensation Insurance,or a certified 10636. E. LIVE OAK
copy thereof(Sec.3800,Lab.C.) CITY ZIP
1046140 STATE FUND ARCADIA CA 91006 LOCALITY
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. I NEAREST CROSS ST.
[],Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
—department. USE ZONE MAP NO.
Date 11—1—9 3Applicant RANDOL ROOFING ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO.
COMPENSATION INSURANCE CLARA AUCH 46-6860 WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDRESS DISTRICT GROUP TYPE C T. F ZONE PROCESSED BY
dollars ($100)or less.) 483 WOODRUFF AVE.
I certify that in the performance of the work for which this permit QIARCADIA, CA ZIP 91007
j--,,roe 2
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 CLASSIFICAT10V APT CONDO
Date. Applicant ADDRESS CLASS NO. 2' DWELL UNITS
NOTICE TO APPLICANT. If, after making 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 RANDOL ROOFING 288-4040 FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS - LIC.NO. P L -
LICENSED CONTRACTORS DECLARATION 529 E. VALLEY BLVD. 451937 SIDE
CITY LIC.CLASS P L
I hereby affirm that I am licensed underprovisions of Chapter 9 SAN GAWRTgT. C— SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. NEW ❑ BK PG , a
License Number 451937 Lic.Class C-39 DESCRIPTION OF WORK ADD ❑ VALUATION O
Contractor RANDOL ROOFINCDate 1-31-94 IRERl JJnJJ_qF, WTTH 915—YEAR ALTER ❑ $ 2,000.00 U
CLASS A FIBERGLAS SHINGLES. REPAIR O
0
0'1 am.exempt under Sec. $ f—
.............. ,.......
BAP.C.for this reason DEMOL ❑
LDMA.PFC#
Date: USE OF EXISTING BLDG. URM ❑ ,
Signature A PLITEL NO.(PRINT) O. - LDMA P # Z
Perm '€9_i_ T
j t n -
❑ I, as owner of the property, or my employees with wages as 2 8— 0 0 Z - -- . ...-.. -.
their sole compensation,will do the work and the structure is ADDRESS 0 3071 .132.31.°
not intended or offered for sale (Section 7044, Business and ,.FINAL DATE 000-- TM
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE - _ - � J egg �'
❑ 1, as owner of the property,•am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? -'"" FINAL BY TOT{AL '"'�� � '��
licensed contractors to construct the project (Section 7044, YES❑ NO❑ f__, 1-,•- -
Business and Professions Code.) CISH LFs.
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING (�'��;'
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH - CHANGE .LFLI
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES. '
I hereby affirm that there is a construction lending agency for YES❑ NO❑
a the performance of the work for which this permit is issued(Sec. ;"I(i(I`—(k sl s 1 ' "
O1 I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING ^�•--+-I JIr�1 `.�' ? `s"
3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, 4 TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS 9257 a A e 1 j e 06
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
m Lender's Address
O OWNER OR AGENT .
o I certify that I have read this application and state under penalty
O of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
o with all countv ordirAnces and State laws relating to building
a constructioV�e;,
y autho' e representatives of/this/county ISSUANCE FEES
m �j.
M to enter u ti operty for insp c on osesaINVESTIGATION FEE TOTAL FEE
� Synature Ap nt �a •
SEE REVERSE FOR EXPLANATORY LANGUAGE