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Home My Public Portal About4949 Kauffman Ave_Buidling_7/9/2015_COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS BUILDING AND SAFETY / LAND DEVELOPMENT LEGAL ID: TR: 15080 IT: 1 ASSESSOR INFORMATION NUMBER: 8589-017-010 TENANT OWNER: DE MOND CHRISTOPI 4949 KAUFFMAN AV TEMP 917804248 APPLICANT: ASCARRUNZ, NESTOR 8619 YOLANDA AVENUE NORTHRIDGE CA 91324 CONTRACTOR: IC -WEST ROOFING CO. 8619 YOLANDA AVE NORTHRIDGE CA 91324 ARCHITECT OR ENGINEER: TEL. NO: C TEL. N0: (818) 701 -5090 - TEL. NO: (818) 701 -5090 - LIC. NO 749881 C39 TEL. NO: LIC. NO: MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 3 00 NO. OF FAMILIES: DWELLING UNITS: APT/CONDI STAT CLASS: NO 21 SCHOOL WITHIN HAZARDOUS AIR QUALITY: 1000 FEET MATERIALS NO NO NO PERMIT EXPIRES 180 DAYS IF 1) WORK DOES NOT COMMENCE, OR 2) WORK IS SUSPENDED OR ABANDONED, OR 3) FAILS TO OBTAIN CODE REQUIRED INSPECTION TEMPLE CITY # 0508 BUILDING PERMIT 9701 LAS TUNAS ALTERATION/REPAIR TEMPLE CITY CA 91780 BL 0508 1507090069 PHONE: (626) 285-0488 EXT: NO. OF CONST BUILDING ADDRESS: SQ. FT STORIES TYPE 4949 KAUFFMAN AV (STRUCTURE: 1800 V -B ( TEMP CA 917804248 NEAREST CROSS STREET: LOWER AZUSA THOMAS PAGE: 597 GRID: AS LOCALITY: TEMPLE CITY CA EXIST BLDG USE: RESID USE ZONE: R-1 ISSUED ON: PROCESSED BY: EXIST OCC GRP: I 107/09/15 SR I SLUGS. NOW ON LOT: VALUATION: FINAL DAT FI/N/AL{(/BY: CODE: 6.650 Iiip'Ac?f f61 FEES PAID ] A/V.LC) � � T Q F RK MAIN HOUSE TEAR OF EXISTING COMPOSITION ROOF, INSTALL NEW 30 FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: YR. SHINGLES COOL ROOF SYSTEM AA BLDG PERMIT ISSUANCE 27.80 AS STATE GREEN BLDG FEE 5650.00 VAL 1.00 SPECIAL CONDITIONS: AC STRONG MOTION RESID 5650.00 VAL 0.70 D2 PERMIT W/O EN -HC 5650.00 VAL 149.40 TOTAL FEES 178.90 APPROVALS DATE INSPECTOR SIGNATURE LOCATION AND SETBACKS SOILS ENGINEER APPROVAL FOUNDATION/TRENCH FORMS SLAB/UNDER FLOOR RAISED FLOOR FRAMING UNDERFLOOR INSULATION FLOOR SHEATHING ROOF SHEATHING SHEAR PANELS FRAME INSPECTION L FIRE SPRINKLER HANGERS INSULATION/WEATHER STRIP INTERIOR LATH/DRYWALL EXTERIOR LATH RATED FLOOR/CEIL ASSEM. RATED WALL ASSEMBLIES RATED SHAFTS/OPENINGS I 1 T -BAR CEILINGS LOT DRAINAGE REPORT ID: DPR261 ROUTE TO: BS0508 OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I. JOB ADDRESS I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by the checkmark(s) I have placed next to the applicable item(s) (Section 7031.5, Business and Professions Code): Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law'(Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): U I, as owner of the property, or my employees with wages as their sole compensation, will do (✓) all of or (_) portions of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the Owner - Builder will have the burden of proving that it was not built or improved for the purpose of sale.). U I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant .to the Contractors' State License Law). I (_): I am exemdt from licensure under the Contractors' State License Law for the following reason: By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year priori to completion of the improvements covered by this permit, I gnnot legally sell a structure that I have built as an owner -builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 oftheBusiness and Professions Code, is available upon request when this application is submitted or at the following Web site: htto://www.lecinfo.ca.00v/calaw.html. Date: Signature of Property Owner or Authorized Agent I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. �Lticense Class 3 % License No. (It /- Date? /.r ContractorSiggaWre WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self - insure for workers' compensation, Issued by the Director of LOCALITY HAZARDOUS MATERIAL DECLARATION Will the applicant or future building occupant handle a hazardous material or a mixture containing a hazardous material equal to or greater than the amount specified on the hazardous materials information guide? Yes ❑ No ❑ Will the intended use of the building by the applicant or future building occupant require a permit for construction or modification from the South Coast Air Quality Management District (SCAQMD)? See permitting checklist for guidelines. Yes ❑ N ❑ �- I have read the hazardous materials information guide and the SCAQMD permitting checklist, I understand my requirem@nts under the Los Angeles County Code Title 2, Chapter 220' Sections 220.100 through 220.140 conceming hazardous material reporting and for obtaining a permit from the SCAQMD. Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit ASBESTOS NOTIFICATION is issued. Policy No. ❑ Notification letter sent to AQMD and/or EPA I have and will maintain workers' compensation i surance, as required by Section 3700 of the Labor Code, for ❑ I -declare that notification of asbestos removal is not the performance of the work for which this permit is issued. My applicable to addressed project. workffrs' c I anon nsur�ncepgwier an RoJrP r err; _ ��DECLARATION REGARDING CONSTRUCTION LENDING Comer Po Icy (umber piretion Date AGENCY Name of Agent Phone Number I certify that, in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions Signature of Applice Date LOBBYIST ORDINANCE CERTIFICATION Complete this section for.permits in Unincorporated Los Angeles County only This is to certify that I, as permit applicant, am familiar with the requirements of Los Angeles County Code Chapter 2.160 at seq., (relating to the Los Angeles County Lobbyist Ordinance) and that all persons acting on behalf of myself complied and will continue to comply therewith through the application process. I hereby affirm under penalty of perjury that there is a Construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code). Lender's Name Lenders Address By my signature below, I certify to,each of the following: I am the property owner or authorized to act on the property.owner's behalf. I have read this application and the information I have provided is correct. I agree to comply with all applicable city and county ordinances and state laws relating to building Construction. I authorize representatives of this county to enter the above -identified property for inspection purposes. Signature of Property Owner or Aut orized Agent Applicant (Print Name) Applicant Signature �cp' .7 Company Name Date e COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS BUILDING AND SAFETY / LAND DEVELOPMENT LEGAL ID: ITR: 15080 LT: 1 ASSESSOR INFORMATION NUMBER: 8589-017-010 1 TENANT: OWNER: IDE MOND CHRISTOPHER;DONNA C 4949 KAUFFMAN AV TEMP 917804248 APPLICANT: IASCARRUNZ, NESTOR 18619 YOLANDA AVENUE INORTHRIDGE CA 91324 CONTRACTOR: JC -WEST ROOFING CO. 18619 YOLANDA AVE INORTHRIDGE CA 91324 (ARCHITECT OR ENGINEER: TEL. NO: TEMPLE CITY # 0508 9701 LAS TUNAS TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: NO. OF CONST SQ. FT STORIES TYPE STRUCTURE: 500 V -B EXIST BLDG USE: DETAC EXIST OCC GRP: BLDGS. NOW ON LOT: FEE DESCRIPTION: TEL. NO: 1 (818) 701-5090- JAA BLDG PERMIT ISSUANCE JAB STATE GREEN BLDG FEE JAC STRONG MOTION RESID ID2 PERMIT W/O EN -HC TEL. NO: (818) 701 -5090 - LIC. NO 749881 C39 TEL. NO: LIC. NO: MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 3 00 INO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS: NO 21 SCHOOL WITHIN HAZARDOUS AIR QUALITY: 1000 FEET MATERIALS NO NO NO I PERMIT EXPIRES 180 DAYS IF 11) WORK DOES NOT COMMENCE, OR 12) WORK IS SUSPENDED OR ABANDONED, OR 13) FAILS TO OBTAIN CODE REQUIRED INSPECTION I REPORT ID: DPR261 BUILDING PERMIT ALTERATION/REPAIR BL 0508 1507090070 BUILDING ADDRESS: 4949 KAUFFMAN AV TEMP CA 917804248 NEAREST CROSS STREET: LOWER AZUSA THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY CA USE ZONE: R-1 JISSUED ON: PROCESSED BY: 07/09/15 SR VALUATION: FIN01100(4 FINrzj2� CODE: FEES PAID IDESC�1,570 cq N OF WORK DETACHED ARAGE TEAR OF EXISTING COMPOSITION ROOF, INSTALL QUANTITY: UOM: AMOUNT:INEW 30 YR. SHINGLES COOL ROOF SYSTEM 27.80 1570.00 VAL 1.00 ISPECIAL CONDITIONS: 1570.00 VAL 0.50 1570.00 VAL 82.20 TOTAL FEES 111.50 ROUTE TO: BS0508 JAPPROVALS LOCATION AND SETBACKS SOILS ENGINEER APPROVAL FOUNDATION/TRENCH FORMS SLAB/UNDER FLOOR RAISED FLOOR FRAMING UNDERFLOOR INSULATION FLOOR SHEATHING ROOF SHEATHING I l6Qk- cls% SHEAR PANELS- FRAME INSPECTION I FIRE SPRINKLER HANGERS INSULATION/WEATHER STRIP INTERIOR LATH/DRYWALL EXTERIOR LATH RATED FLOOR/CEIL ASSEM. RATED WALL ASSEMBLIES RATED SHAFTS/OPENINGS IT -BAR CEILINGS LOT DRAINAGE DATE INSPECTOR SIGNATURE OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I JOB ADDRESS I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reasons) indicated below by the checkmark(s) I have placed next to the applicable item(s) (Section 7031.5, Business and Professions Code): Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): L) I, as owner of the property, or my employees with wages as their sole compensation, will do (✓) all of or L) portions of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the Owner - Builder will have the burden of proving that it was not built or improved for the purpose of sale.). U I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a licensed Contrha for pursuant.to the Contractors' State License Law). L). I am exemdt from licensure under the Contractors' State License Law for the following reason: By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year priorlto completion, of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner -builder If it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and Professions Code, is available upon request when this application is submitted or at the following Web site: htto://www.leainfo.ca.aov/calaw.html. Date: Signature of Property Owner or Authorized Agent I hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class C J License No. 7/i9V'*� Date]'%/ Contractor Signature WORKERS' COMPENSATION DECLAMATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self - insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy No. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of t4 work for which this permit is issued. My wgycej's' catio ins�n]cerrl Iibs numar 6 Carrier Polr,v Num err Expiration DateU / Name of Agent Phone Number I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions Signature of Appg&bf ate LOBBYIST ORDINANCE CERTIFICATION Complete this section for permits in Unincorporated Los Angeles County only This is to certify that I, as permit applicant, am familiar with the requirements of Los Angeles County Code Chapter 2.160 at seq., (relating to the Los Angeles County Lobbyist Ordinance) and that all persons acting on behalf of myself complied and will continue to comply therewith through the application process. Applicant (Pent Name) Applicant Signature Company Name Date LOCALITY HAZARDOUS MATERIAL DECLARATION Will the applicant or future building occupant handle a hazardous material or a mixture containing a hazardous material equal to or greater than the amount specified on the hazardous materials information guide? Yes ❑ No ❑ Will the intended use of the building by the applicant or future building occupant require a permit for construction or modification from the South Coast Air Quality Management District (SCAQMD)? See permitting checklist for guidelines. Yes ❑ N o ❑ I have read the hazardous materials information guide and the SCAQMD permitting checklist, I understand my requirements under the Los Angeles County Code Title 2, Chapter 220' Sections 220.100 through 220.140 concerning hazardous material reporting and for obtaining a permit from the SCAQMD. ASBESTOS NOTIFICATION ❑ Notification letter sent to AQMD and/or EPA ❑ I declare that notification of asbestos removal is not applicable to addressed project. DECLARATION REGARDING CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a Construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code). Lenders Name Lender's Address By my signature below, I certify to,each of the following: I am the property owner or authorized to act on the property.owner's behalf. I have read this application and the information I have provided is correct. I agree to comply with all applicable city and county ordinances and state laws relating to building construction. I authorize representatives of this county to enter the above -identified property for inspection purposes. Signature of ppPAY Ow or Authorized Agent < Date .- COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS BUILDING AND SAFETY / LAND DEVELOPMENT LEGAL ID: ITR: 15080 LT: 1 1 ASSESSOR INFORMATION NUMBER: 8589-017-010 1 TENANT: OWNER: IDE MOND CHRISTOPHER;DONNA C 4949 KAUFFMAN AV TEMP 917804248 APPLICANT: JASCARRUNZ, NESTOR 8619 YOLANDA AVENUE INORTHRIDGE CA 91324 CONTRACTOR: IC -WEST ROOFING CO. 18619 YOLANDA AVE INORTHRIDGE CA 91324 (ARCHITECT OR ENGINEER: TEMPLE CITY # 0508 9701 LAS TUNAS TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: NO. OF CONST SQ. FT STORIES TYPE STRUCTURE: 400 V -B EXIST BLDG USE: STORA USE ZONE: R-1 (EXIST OCC GRP: TEL. NO: JBLDGS. NOW ON LOT: VALUATION: 1 1,278 TEL. NO: (818) 701 -5090 - TEL. NO: (818) 701 -5090 - LIC. NO 749881 C39 TEL. NO: LIC. NO: EMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 3 00 INO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS: NO 21 SCHOOL WITHIN HAZARDOUS AIR QUALITY: 1000 FEET MATERIALS I NO NO NO I PERMIT EXPIRES 180 DAYS IF 11) WORK DOES NOT COMMENCE, OR 12) WORK IS SUSPENDED OR ABANDONED, OR 13) FAILS TO OBTAIN CODE REQUIRED INSPECTION FEE DESCRIPTION: JAA BLDG PERMIT ISSUANCE JAB STATE GREEN BLDG FEE JAC STRONG MOTION RESID ID2 PERMIT W/O EN -HC REPORT ID: DPR261 FEES PAID QUANTITY: UOM 1278.00 VAL 1278.00 VAL 1278.00 VAL TOTAL FEES ROUTE TO: BS0508 BUILDING PERMIT ALTERATION/REPAIR BL 0508 1507090071 BUILDING ADDRESS: 4949 KAUFFMAN AV TEMP CA 917804248 NEAREST CROSS STREET: LOWER AZUSA THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY CAI ISSUED ON: PROCESSED BY: 107/09/15 SR FINAL TE FINAL B CODE: 6 ld, IDESCRIOTION OF WORK STORAGE ROOK TEAR OF EXISTING COMPOSITION ROOF, INSTALL NEW AMOUNT:130 YR. SHINGLES COOL ROOF SYSTEM 27.80 1.00 ISPECIAL CONDITIONS: 0.50 82.20 111.50 APPROVALS DATE INSPECTOR SIGNATURE LOCATION AND SETBACKS SOILS ENGINEER APPROVAL FOUNDATION/TRENCH FORMS SLAB/UNDER FLOOR RAISED FLOOR FRAMING UNDERFLOOR INSULATION FLOOR SHEATHING ROOF SHEATHI��r�/ le -11 SHEAR PANELS I! rr FRAME INSPECTION FIRE SPRINKLER HANGERS INSULATION/WEATHER STRIP INTERIOR LATH/DRYWALL EXTERIOR LATH RATED FLOOR/CEIL ASSEM. RATED WALL ASSEMBLIES RATED SHAFTS/OPENINGS IT -BAR CEILINGS LOT DRAINAGE OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION JOB ADDRESS 1- I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by the checkmark(s) I have placed next to the applicable item(s) (Section 7031.5, Business and Professions Code): Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): U I, as owner of the property, or my employees with wages as their sole compensation, will do (./) all of or (_) portions of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the Owner - Builder will have the burden of proving that it was not built or improved for the purpose of sale.). U I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a licensed Contrb�tor pursuant .to the Contractors' State License Law). U I am exeml t from licensure under the Contractors' State License Law for the following reason: By my signature below I acknowledge that, except for my personal residence in whicl1 I must have resided for at least one year prior) to completion; of the improvements covered by this permit, I c�'nnot legally sell a structure that I have built as an owner -builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and Professions Code, is available upon request when this application is submitted or at the following Web site: httq://www.leainfo.ca.gov/calaw.html. Date: Signature of Property Owner or Authorized Agent I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class r-'YP License No. 7 >i � Date 7/�jcl Contractor Signatur�tr_��__ WORKERS' COMPENSATION DECLA�iT`ION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self - insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy No. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My ersl o.�' p ion ' s a 7 �/,arrigr gpdp�cYlmu �er ale: Carrier �i o(cy'Numberr Ex�pir�tion Date ro Name of Agent Phone Number _ I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions Signature of Ap k antes Date LOBBYIST ORDINANCE CERTIFICATION Complete this section for permits in Unincorporated Los Angeles County only This is to certify that I, as permit applicant, am familiar with the requirements of Los Angeles County Code Chapter 2.160 et seq., (relating to the Los Angeles County Lobbyist Ordinance) and that all persons acting on behalf of myself complied and will continue to comply therewith through the application process. Applicant (Print Name) Applicant Signature Company Name Date LOCALITY HAZARDOUS MATERIAL DECLARATION Will the applicant or future building occupant handle a hazardous material or a mixture containing a hazardous material equal to or greater than the amount specified on the hazardous materials information guide? Yes ❑ N o ❑ Will the intended use of the building by the applicant or future building occupant require a permit for construction or modification from the South Coast Air Quality Management District (SCAQMD)? See permitting checklist for guidelines. Yes ❑ N o ❑ / I have read the hazardous materials information guide and the SCAQMD permitting checklist, I understand my requirem nts under the Los Angeles County Code Title 2, Chapter 220' Sections 220.100 through 220.140 concerning hazardous material reporting and for obtaining a permit from the SCAQMD. ASBESTOS NOTIFICATION ❑ Notification letter sent to AQMD and/or EPA ❑ 1 declare that notification of asbestos removal is not applicable to addressed project. DECLARATION REGARDING CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a Construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code). Lender's Name Lender's Address By my signature below, I certify to;each of the following: I am the property owner or authorized to act on the property. owner's behalf. I have read this application and the information I have provided is correct. I agree to comply with all applicable city and county ordinances and state laws relating to building construction. I authorize representatives of this county to enter the above -identified property for inspection purposes. Signature of Pro r or Authorized Agent r Date 7/%��