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Home My Public Portal About9129 EMPEROR AVE_Building__ APPLICATION FOR BUILDING PERMIT' • COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUI ING A RES or a certificate of Workers' Compensation Insurance,or a certified 4e copy thereof (Sec.3800,Lab.C.) CITY r i ZIP, F� Policy No. Company gig Ci:- 4 917 J LOCALITY''^ n' (`� SIZE OF LCT NO.OF BLD S.N ON L 1�-� � v i C4 ❑ Certified copy is hereby furnished. o 6 NEAREST CROSS ST. ❑ Certified copy is filed with the County building inspection TRACT BLOCK LOT NO. On K . department. Q 17 USE ZONE MAP NO. `. � a/ Date Applicant ASTES_ AP BOOK PAGE PARCEL 1 O g� Z 1 0/� (/� t SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE - WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADD SS do tars($100)or less.) 2 DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY CIT ZIP I certify that in the performance of the work for which this permit , t j 5S"Q� ��3 3 is issued, I Shall not employ any pe son in any manner SO as t0 ARCHITECT ORE GINEER TEL NO. become subject to the Workers'CO pensation Laws. STATISTICAL CLASSIFICATIONAP O Ibb Date App �+ ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLIC NT If, ter making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Sh Id b ome subject to the Workers'\ CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions o the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FRONT P Y P P ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION SIDE CITY LIC.CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF`STORIES NO.OF FAMILIES SEWER MAP Professions Code,and my license is in full force and effect. Z 5, / NEW 0 BK PG �- d License Number Lic.Class DES IPTION OF ORK ��W � ,D tX Z3i l U ADD � VALUATION � , Q 0 Contractor Date ALTER ❑ F4' 1 Sul tdiw ❑ I am exempt under Sec. � e''1(bb lY1 t5 tN REPAIR D �d.000 1'CCToi B.&P.C.for this reason DEMOL ❑ LDMA P/C# k_', �,�j,� l W Date: USE OF EXISTING BLDG. URM ❑ " ' 0- ITEMS (n Signature APPLICANT(P NT) T NO. LDMA Perm# T _ v was owner of the property, or my employees with wages as hA cm U �, . Z •TOTAL 50 - 50 heir sole compensation, will do the work and the structure is ADDR T O - CHECK not intended or offered for sale (Section 7044, Business and 2 r2r ToyRte C& FINAL DA JE Q =•J_ Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIALAMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY l•REFI IUG s 1113 El 1, as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE _// _ . licensed contractors t0 CODStrUCt the project (Section 7044, YES❑ NO❑ �I f ) Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDINGL -f�liZ yl iU/ ?• OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH - _ CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR rj 1.i 111 1 { �.��o�5 GUIDELINES. 4 1 P'1 f I hereby affirm that there is a construction lending agency for ..j 1 YES 0 NO El w the performance of the work for which this permit is issued(Sec. O� [HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING _ 3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, - (;y:; Y N 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. : h C - CL Lender's Address `1i1 i 3:I .u: OOWNER OR AGENT T. _ o I certify that I have read this application and state under penalty I Mc O of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE --s N with all county ordinances and State laws relating to building 2 Co i 3. TOTAL 35 .6. m 83 � constr ction, and hereby authorize representatives of this County -- ISSUANCE FEE �-a (+ l �� to en upon the above-mZ�ntione property for inspection purposes. Iv H "� W'-�1.5 WVESTIGATIO FEE y / � CHANGE -.00 Signaof APgli—I w Agnt Dae 35 V� SEE REV -F PLANATORY LANGUAGE (qq12 _ APPLICATION FOR BUILDING PERMIT �1 COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING AD Ess r BUI ING RE I2 M ro I 1 hereby affirm that I have a certificate of consent to self insure, 1Z ��+.. or a certificate of Workers'Compensation Insurance,or a certified CIS , zIP copy thereof(Sec.3800,Lab.C.) + LOCALITY Policy No. Company SIZEOT NO.OF BLDGS.NOW LO OF ❑ Certified copy is hereby furnished. X NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. 1109 USE ZONE MAP NO. JC ' ASSESSOj QPBOOK PAGE PARCEL //�� a Date Applicant .7 4,2- 2 6 /�,� 1 SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL.NO. ' 1 / COMPENSATION INSURANCE 01� WITHIN 1000 FT OF SCHOOL? YES NO ADDRESS (This section need not be completed if the permit is for one hundred 4Fiw t*�-. �e DISTRICT GROUP TYPE C NST. FIRE ZONE PRO SED B dollars($100)or less.) CI zIP I certify that in the performance of the work for which this permit Q � 5--060-� �, is issued, I shall not employ any person in any manner so as to ARCRITECT OR ENGINEER TEL.NO. become Subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT NDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of CONTRACTOR TELNOREQUIRED TOTAL SETBACK FROM EXIST . . Exemption, you should become subject to the Workers' SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION CITE' LIC.CLASS SID 13- C3- 1 hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and S SIZE NO.OF STORES NO.OF FAMILIES NEW ❑ BK O Professions Code,and my license is in full force and effect. • PG CD DESCRIP ION OF ❑ W License Number Lia WORK ADD VALUATION polo. Class � � I Contractor Date ALTER ❑ yZ ❑ I am exempt under Sec. REPAIR ❑ $ g0co,0 B.BP.C.for this reason DEMOL ElLDMAP/C It Date: USE OF EXISTING BLDG. -LIR M ❑ Signature APPLICANT(PRINT) L.NO. LDMA Perm p I, as owner of the property, or my employees with wages as Z = their sole compensation,will do the work and the structure is ADDRESS 2 (lr :? °$ not intended or offered for sale (Section 7044, Business and17 41 FI DA Q 7 5 0 � Professions Code.) WILL THEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL ." OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN J �T_ +_, ❑ 1, as owner of the property, am exclusively,contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL Y Q j s licensed contractors to construct the project.(Section 7044, Business and Professions Code.) YES C1 No 11 TOTAL 12�o __ 0 WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH [HECK 123.50 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. r� Ihereby affirm that there is a construction lending agency for YES❑ NO❑ CHANGE the performance of the Work for which this permit Is issued(Sec. 'PERMITTING READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD m 3097,CIV.C.). PERMITTING 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 �}('� q ` /�^7 J+ySi Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.• �{I 00-'11�1i.31 TF f Lender's Addressj jti 1 s `,°7 ID OWNER OR AGENT + -- o' I certify that I have read this application and state that the above information is correct. I agree to comply with all county P.C.FEE PERMIT FEE ,J o ordinances and State laws relating to building construction,and I--' a. hereby authorize representatives of this County to enter upon ISSUANCE FEE 1. , O Oe a ve-mentioned property for inspection purposes �+ 0 INVESTIGATION FEE TOTAL FEE ^ re of ApplWtl aA•ni Dab d SEE REVERSE FOR EXPLANATORY LANGUAGE ,OR KERS'-COMPENSATION DECLARATION r insure borothat a certi cate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING ��u"�e - tion department. ADDRESS A Date Applicant CITY ZIP LOCALITY L pp NO. OF BLDGS. - NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS'- SIZE OF LOT ox I NOW ON LOT CROSS ST. COMPENSATION INSURANCE BASSESSOR - (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE 6 Z PARCEL6)3 hundred dollars ($100) or.less.) TEL. OWNER NO• USE ZONE MAP j b I certify that in the performance of the work for which this U NOSPECIAL. permit is issued, I shall not employ any person in any manner ADDRESS Z Vim- CONDITIONS so as to become subject to the Workers'C pen ation Laws. O CITY ZIP �1 , Date /- ~ 7`7/ Applicant ARCHITECT OR. TEL. DISTRICT GROUP TYPE FIRE PROC Y 0 NOTICE TO APPLICANT: If, after maki this Certificate of ENGINEER NO. / �j CONST. ZONE Exemption, you should become subject to the .Workers' /1n K Compensation provisions of the Labor Code, youD B ,must forth- ADDRESS + ✓✓✓"' CL UJI with comply with such provisions or this permit shall be — AR TEL. STATISTICAL CLASSIFICATION AP-K. C O. N deemed revoked. - CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION �- UCCLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS f Q No'. SEWER MAP (commencing with Section•7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. OF NO. OF CHECK License Number Lic. Class SIZE DRIES FAMILIES ONE VALUATION contractor < <+ ateZ�ZZ DESCRIPTION OF WORK NEW 44 L xe ❑ �_� El I am ept'un er Sec. 6 I j. A[ pop- ALTER D ► ALTER B.&P.C. for this reason - REPAIR ❑ 1 Il 0,a� Date: "?iZ USE OF DEMOL ❑ EXISTING BLDG. Signature APPLICANT TEL, FINA O NER-B ILDER DECLA ATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License DAT Law for the following reason (Section 7031.5, Business and ADDRESS 'FINAL _ 8 Professions Code): PRESENT By At�•�•) .T BUILDING 7 El 1, as owner of the property, or my employees with ADDRESS 3307 10 5.25 wages as their sole compensation,will do the work and the structure is not intended or offered for'sale(Section LOCALITY , ITEM 7044, Business and Professions Code.) MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. TOTAL 105 25 with licensed contractors to construct the project (Sec- ADDRESS CHECK 10 5.225 tion 7044, Business and Professions Code.) REQUIRED OM TOTAL SETBACK FREXIST. ( ��I3! YARD HWY CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH CHANGE I hereby affirm that there is a construction lending agency for FRONT the performance of The work for which this permit is issued P.L. (Sec. 3097, Civ. C.). } r"j Lender's Name qCJ q�rr, m /10�5 LDMA Ref. # 91019 1 tV, �f:47 P.C..Fee$ Permit Fee OC 3 Lender's Address I 1 certify that I have read this application and state that the Issuance Fee / O LDMA P/C# a above information is correct. I agree to comply with all County Investigation Fee 6 ordinances and State laws relating to building construction, Total Fee LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-meat ned p aperty for inspection purposes. % Z.��/y SEE REVERSE FOR EXPLANATORY LANGUAGE Sig tature of plicant or'Agent--. Date