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Home My Public Portal About9406-9510-9512 WOODRUFF AVE_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BS!LD ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUSpING ADDRESSor a certificate of Workers'Compensation Insurance,or a certified C , sl LYFr copy thereof(Sec.3800,Lab.C.) CRY ZIP LTY ' 9 Policy No. Company SIZE OF LOT NO.OF BLDG&NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS Sr ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. I I USE ZONE MAP NO. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. f COMPENSATION INSURANCE Zoe G VL .�_©, WITHIN 1000 FT.OF SCHOOL? utas No (This section need not be completed if the permit is for one hundred ADDRESS dollars($100)or less.) DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY I certify that in the performance of the work for which this permit CITY ZIP D /f X- 3 is issued, I shall not employ any person in any manner so as t0 ARCHITECT OR ENGINEER TEL NO. ,4 became subject to the Workers' nsat' n Laws. 7 ^. ) � STATISTICAL CLASSIFICATION APT CONDO Date` Applicant , �✓�^�.+�� ADDRESS CLASS NO. C=2 I DWELL UNITS NOTICE TO APPLICANT• If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CON RRAACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith vl �� /nC��/�CJ�i� FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS /, PL LICENSED CONTRACTORS DECLARATION 7�ifJ �� C� ' �v 679 SIDE LIC. PL I hereby affirm that I am licensed underprovisions of Chapter 9 [�-CjASS 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 li ens is in full force a/r�of NEW BK PG ® a License Numb �� Lia Classy`7----) DE CIC N OF R / ADD ❑ $LUAT1oN Contracto ate 7 7' C' ALTER ❑ °C ❑ I am exempt under Sec. REPAIR ❑ C BAP.C.for this reason CPA? 5 ?7 VA7 $ H DEMOL ❑ L LDMA P/C# USE OF EXISTING BLDG. Date: URM ❑ � � Signature APPLICANT(PRINT) TEL NO LDMA Perm# 3 ❑ I, as owner of the property, or my employees with wages as Z 1"t—i °IT r their sole compensation, will do the work and the structure is ADDRESS a' F 3303 �._Ia°�ti, not intended or offered for sale (Section 7044, Business and FINAL DATE a Professions Code.) WLL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL = 1 f C L OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J r � -� El 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY j I � .EI.��..tl a +'J' licensed contractors to construct the project (Section 7044, YES 1:1 No❑ Business and Professions Code.) i: 1IJL.°`l-, 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 QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR �� 31` GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ NO❑ Tv the performance of the work for which this permit is issued(Sec. _ 0) 1 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING jay/ N 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. I I]i?--I�I,�I; J• i f 77 TITLE 2.CHAPTER 2.20 SECTIONS 2 20.100 THROUGH 2 20.140 CONCERNING HAZARDOUS Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. � 67391 Art 9:20 o Lender's Address O OWNER OR AGENT o I certify that I have read this application and state under penalty 4 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE N with all county ordinances and State laws relating to building mconstr t1 nd hereby authorize representatives of this County ISSUANCE FEE / �f� a to e n e a - 'oned property for inspection put oses. /O T(J m "0 A°p a INVESTIGATION FEE TOTAL FEE Sa /� J'' 30 1` mar u uM a m O0= SEE REVERSE FOR EXPLANATORY LANGUAGE