HomeMy Public PortalAbout9619 WOODRUFF AVE_Building__ APPLICATION F.QR ;BUILbING PERMIT
- CQUNTY OF LOS'ANGELd fi' I BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION - FOR APPLICANT TO FILL IN BUILDlyr3���s
I hereby affirm that I have a certificate of consent to self insure, BUI IN Aqp SS R f�'
ve ��lJ
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) / ) -7��
Policy No. Company CITY Y op �L J ZIP / LOCALITY
SIZE
SIZE OF NO.OF BLDGS.NOW ON LOT I
❑ Certified copy is hereby fumished. NEAREST CROSS ST.
❑ Certified copy'Is filed with the county building inspection TRACT BLOCK- LOT NO.' I
department. USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE/ PARC /�
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWN �G�� �J�•//r' T C�o'7' Sf� I YES NO
COMPENSATION INSURANCE !i vInTHIN 1000 Fr of scHooL�
(This section need not be completed if the ermit is for one hundred ADORE
p � DISTRICT GROUP TYPE CONST, FIRE ZONE PROCESSED BY
dollars($100)or'less.)
I certify that in the performance of the work for,which this permit\Q
is issued, I shall not employ any person in any manner so as to \ CIT
JWieHF;Ey ZIP EL NO�� O� ��
become subject to the Workers'Compensation Laws. ,KEN &Lp et L eft.qo f STATISTICAL CLASSIFICATION APT, CONDO
Date Applicant ,;Iva ADDRESS CLASS NO. 40/ DWELL UNITS
N07ICE TO APPLICANT If, after making this Certificate of uO�T �AS� REQUIRED' TOTAL SETBACK FROM EXIST
j SW
Exemption, you should become subject to the Workers' } CONTRALTO TEL NO. SET BACKYARD HWY PR NE WIDTH
Compensation provisions of the Labor Code, you must forthwith ROM
comply with such provisions or this permit shall be deemed revoked. ADORES LIC.NO., FF L r ACCTo4
;
LICENSED CONTRACTORS DECLARATION I CITY LIC.CLASS PL SIDE 03 1871 .51
I hereby affirm that I am licensed uhderprovislons of Chapter 9 SEWEIIR MAP
(commencing with Section 7000)of Division 3 of the Business r 6 SO.Fr SIZE NO.OF STORIES NO.OF FAMILIES NEW BK I' PG TOTAL 1�7$ Sia
Professions Code,and my license is in full force and effect. c� ryv p o
DESCRIPTION O./ , CHECK 1878'1878.5 U
License Number •Lic.Class ADD� ❑
VALUATION
Contractor Date I ALTER ❑ $ 1����U CHANGE .001z
❑ 1 am exempt under Sec. REPAIR ❑ $ I U
B.BP.C.for this reason I DEMOL [ILDMA',P/C# 0000-0001 7/20/95ul
Date: USE OF EXISTING BLDG. URM ❑ L D.
Signature MoJL
1 AM10o40z
APPLICANT(PRINT) TEL NO. ' LDMA'Perm# nnw4 B Z
❑ I, as owner of the property, or my employees with wages as. ZO026q_ 4.
their sole compensation,will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL'DATE" Q
1 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL I' ! '
® I,.as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q 1 ITEMS
FINAL•BY
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE?
licensed contractors to construct the project (Section 7044, YES ElNO❑ �q o
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDUNG BY-THE APPLICANT OR FUTURE BUILDING '
CUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
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❑ CHANGE .00
CM the 7,Civ.
C.) Of the Work for 11VhICh this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ,
3097,CIV.C.) 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
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE 6CAOMD. ,
o Lender's Address
OWNER OR AGENT .• ..
c I certify that I have read this appjication and state under penalty 0000_0001
e of perjury that the above information is correct.I agree to comp) P.C.FEE PERMIT FEE I q�� rgT}
a with all county ordin*as
and"State laws relating to building / •construction, ani he aorize representatives of this County ISSUANCE FEEm to p nt ned property for inspection purposes, Q
/CD
DM
FEE TOTAL FEE eJ / 432 All
9...5.5
Ggromre m
SEE REVERSE FOR EXPLANATORY LANGUAGE (' '