HomeMy Public PortalAbout4958 LOMA AVE_Building__ l�G°�G°U � W FOGS t.� iOL�D� �:[ . p�G� i.p� .
: COUNTY ; ANGELES -` _' SOIL NG AND SAFETY' =_ -
; '
WORKER'S COMPENSATION DECLARATION ;=«'•,'i FOR APPLI ANT TO FILL INz �' � • BUILDI[�G AODREs$?� ',
I hereby'affirm that I have'a certificate"of consent to-�self Insure, BUILDIN��G'•II A/D�DRESS
or a certificate of that,
Insurance,or',a certified `0 f5 8 ' L-0 v"A `ave
copy thereof(Sec 3800,Lab.C) ; CITY' ZIP/ "rT
LOCALITY
POhcy'NO Company 1 '• ` `tel �7��'''
SIZE,OF LOT NO OF BLDGS NOW ON LOT ,
❑ Certified copy,ls hereby furnished Six(?i o„ -NEAREST CRO ST '
❑ Certified copy is,filed with the•county building Inspection; ' TRACT BLOCK 'LOT NO '. r ,• - - '' 3
department ' ; - - .� '• USE ZONE .MAP NO, +
''� •t-`'`�" •'t a .-`
ASSESSDR MAP BOOK. PAG�l/, FARCE
-
Date. Applicarit _ ' ri �'
O ,, _ T SPECIAL CONDITIONS
s - - OWNER TEL'NO r '_- ,
CERTIFICATE OF EXEMPTION,FROM WORKERS'. ., l'S0� S� YES NO
COAAPENSATION INSURANCE Q 1-- —�Z WITHIN 1000 FT OF SCHOOLS --
ADDRESS. .Girl,.•
(This'section need not°6e completed if the permd is for one'hundred tf -t J DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
dollars,($100)or less) " _; �' 94 > 'L 0•f� e.
Y, - CITY ZIP
I certify that,In the per
rformance of the work Yfo'whicFi'this'permlt'
is Issued, I'shall not employ any,person In.any•manner'so as to �'��~ ✓�
ARCHITECT OR-ENGINEER .TEL NO _
become subject t0:the Workers'Compensation Laws - - . • , , _ ,r', STATISTICAL CLASSIFICATION - '� APT CONDO '
o _ ,
Date Applicant -uF •'t ''G•r ADDRESS - - - CLASS NO' - DWELL UNITS._71f_
NOTICE TO APPLICANT•.lf;.,after 'making,'tfiis Ce�ta,cC to of ti - REQUIRED, TOTAL SETBACK FROM EXIST
Exemption, you 'should 1 become subject', to the' 'WorkerS' CONTRACTOR' '`( y TEL NO, ?•' ` SET BACK" YARD.^ HWY PROP,LINE TH „
Compensation provisions of ttie Labor Cod&,'you'must forthwith, t _ CSU - 4Q-S-�-7&(,
FRONT
comply with such provisions or,,this perrrld shall be deemed revoked ADDRESS - ��qq /NO P,L _
•ti,. t"j�.Fi OIL- � tU0� �56-- 24:t- SIDE' " ^d,
LICENSED CONTRACTORS DECLARATION � ' e n � uc c Ass PL
ZZ, { O
-herebyaffirm that I am licensed.tunderprovisions of,Cha ter 9 �D eA I, - _
P _
(commencing with Section 7000)of DI_vision 3 of the Business ana SQ FT-,SIZE NO OF STORIES NO OF FAMILIES SEWER MAP y\•:, _-T:3
f?rofess(ons Code,and my license m f Il force and effect_ 7 f� NEW BK PG _ _�(:fO
r F-
' DESCRIPTION OF WORK •: VALUATION -^o- ^ -
' License Number Lc Class, �- �= ADD ❑ i is U
LLI
Contractor �' Date, 4 ALTER ❑• $Y �n _ ' =
Fo-
REPAIR ❑ - Z
❑ I am exempt.under Sec "' c $ c ly i " ,7 j'
B&PC for this reason _—� �- - A -
USE OF EXISTING BLDG yDEMOL ❑ LDMA P/C• - 3.' - `„a=;_.- sj ',4;
A '11Date�T URM ❑l .
Signature APPUCA (PRINT") TEL NO <. LDMA Perm# /�
+ ,jam s'-,31' -ix,='tH-Yk,LL TI .�q5,.,-.._ ..•,^s_.n !i-^.
❑ I, as owner of the property;.or my,employees.with wages=as �' �'� �• YY Z 'r •. =' a r'
O
their sole compensation;,wiN'do the-work,and the structure is ADDRESS / + -f .7•�., �,^ - y }
not mtended,op offered for,sale (Section 7044, Business and T / 4 !7 l R` FINAL DATE
Professions Code) - 2 tt" R
WILL THE OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATEI At
RIAL ZJ' +'��' 2t''t+At_'i!
OR A MIXTURE CONTAINING A HAZARDOUS"MATERIAL EQUAL TO OR GREATER THAN THE - J y
I, as Owner,of the property,'am exclusively-contracting with AMOUNTS SPECIFIED ON THE•HAZAADOUS MATERIALS INFORMATION GUIDES FINAL BY F _
licensed contractors to construct the rproject (Sechon 7044,
Business and Professions Code)' , 1. • YES❑.'• No❑WILL THE INTENDED USE OF THE BUIDUNG BY,THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR,MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY'MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR ` ti ' + e 4
GUIDELINES , - .,•�,.,,,T
I hereby affirm that there is a_coristructlon lending agency for' Yes El N611,
the performance of the work for which this permit Is issued
3097,:CIv C s I RAVE CHECKLIST
I HE UNDERSTAND MY
ENTS TION UNDER
THE LO D THE SCAQMDPERMITTING / _ • • - ,
CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS'ANGELES COUNTY CODE, ,
,:.. TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS ,
!Za Lender's Name - MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD
Lender's Address
It , OWNER OR AGENT -• _ - .,
I,certify-that I have read this'application and state under penalty
a
-of perjury that the above mformation
;s correct (;agree-to comply PC FEE PERMIT FEE
o_ /0 '�/�
(/
fn with all-county ordinances'and.State laws, relating-to building' r ' _
M gte
Uc ion, and hereby authorize representatives of this-County ISSUANCE FEE
er pon h ove mentioned property for ins h pu pose
7. 76
�� INVESTIGATION FEE TOTAL FE�E/(� -
• M ve r,t a•Agent + De1e� ' V l D
SEE REVERSE FOR EXPLANATORY LANGUAGE