HomeMy Public PortalAbout6266 LOMA AVE_Building__ AP, PUCAMON FOR BULUNG PERNT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING ADDRESS
WORKER'S COMPENSATION DECLARATION - '
I hereby affirm that I have a certificate of consent to self Insure, BUILDItJG.AD D ES
or a certificate of Workers Compensation Insurance,or a certified ^
copy thereof(Sec 38000, Lab C) ,,. CIT=, ZIP
Policy No �3�a•/ Company +.] '4 7e ""^ le ��1 l�ON LOCALITY ,
SIZE O LCT NO OF BLDGS NOW ON LOT
X ❑ Certified copy Is hereby furnished '• - NEAREST CROSS STO'
Certified copy`is,fled with the county budding inspection TRACT BLOCK LOT NO _
USE ZONE MAP NO
department �/ ,I _
Date
Applicant /70�� IK� ASSESSOR MAP'BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS" TEL NO
COMPENSATION INSURANCE
WITHIN 1000 FT OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDRESS�+ /
dollars'($1OO)or less) p DISTRICT GROUP TY CONST FIRE ZONE PROCESSED BY -
CITY/� l e ZIP Q��O - t
.I certify that in the performance of the work for which this permit j (J `�p -
.is issued, I shall not,employ any person in any manner so as to C
become subject to the Workers'Compensation Laws ARCHITECT ENGINE R TEL NO
,STATISTICAL CLASSIFICATION APT CONDO
'Date Applicant ' ADDRESS .CLASS NO DWELL UNITS
` NOTICE TO APPLICANT If, after making this Certificate 'Of' REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the -Workers' CONTR TOR /4, TEL NO SET BACK YARD HWY - PROP LINE WIDTH
Compensation:provisions of the Labor Code, you must forthwith 2FRONT
comply with such provisions.or this permit shall be deemed revoked gppREgg�� LV �j 'P L'
LICENSED CONTRACTORS DECLARATION 7Sb / �' SIDE
CITY / C �` LIC CLA P L
I hereby affirm that I am.licensed underprovlsions 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,, . - d
Professions Code,and my license is in'full force and effect •a7/4r I I NEW ❑ BK PG 0
License,Number LIC Class ` — j� DESC TIO�OF WORK '- ADD ❑ •VALVA ON > V
Contractor an Date /O '/� 93 p7FiY1 30 ALTER ❑ $ D'o o
❑ I am exempt under See , fD/1J S/Tc•� REPAIR -❑ $ O
B&PC for this reason /n� o ef x.,/q DEMOL ❑ W
LDMA P/C# _
Dat 'USE O EXI G BLDG- - �"
Signature X—If URM ❑ i-i1-'_T a IL Z
APPLI T(PRINT) ,,/ _-, TEL,NO-' .LDMA Perm#`
El 1, as owner of the pro rty, or my,,employees wltli wages as �� r P/r d i-�?5FG z 3303
their sole compensation, will do the work and the structure is ADDRESS``�� ''�Q��, / /� _/ O - I�+ 1-10
not intended or offered for sale (Section 7044, Business and "l2� l ea 10Ade-i'`K��/�C 9 FINAL DATE a iO
Professions Code) qq if {I
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL $y�ki�
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
❑ I, as owner of the property, am exclusively,Contracting with FINAL BY > '} 'Q'
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES TOTAL licensed contractors to construct the project (Section 7044, _ t O AL _ .4 F
40
Business and Professions Code) YES❑ ,NO❑ _
WILL-THE•INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING t_HE K iIf•�a$?j
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH,. _
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR i °I ill
GUIDELINES - '.•!-4hh�l7E
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 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
3097,CIV C)
N CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, I��It t—F1� •l�i� �
Lender's Name TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS
, MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD fir• •.„°
o Lender's Address '-1-i a x AM ° 4
O OWNER OR AGENT -
o I certify that I have read this application and state under penalty
of perjury that the above information is correct I agree to comply PC FEE PERMIT FEE
with all county rdinances and State laws relating-to budding
co c`onstruc d hereby authonz epresentatves of this County ISSUANCE FEE
to the bove yltion/lproper y for inspection puprpos�jes`7 Q
L%'�1/ '� �D�, (J INVESTIGATION E - d0 TOTAL FEE
� �mm pmanl« em Datei
SEE REVERSE FOR EXPLANATORY LANGUAGE