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HomeMy Public PortalAbout5438 ENCINITA AVE_Building__ f - APPLICATION FOR BU10M., G PERMIT BUILDING AND SAFETY COUNTY OF LOS ANGELES p . � d WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADD , I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS cr�✓L7`� or a certificate of Workers' Compensation Insurance,or a certified fit'�' Awe— copy thereof (Sec.3800,Lab.C.) CITY ZIP s,A� remvkL CAI LOCALITY Policy No. Company SIZE OF'LOT% NO.OF BLDG$.NOW ON LOT ❑ Certified copy is hereby furnished. 3 ` NEAREST CROSS .Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. •�— oo USE ZONE MAP NO. Date Applicant V-SVfVP.i 1 {�°a OWESSOF. QI? PAGE „/ PARCEL/ � �: �OY G/n'"� (� SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ; TEL NO. YES NO COMPENSATION INSURANCE 4 WITHIN 1000 FT OF SCHOOL? (This section need not be completed if the permit is for one hundred ADDRESS OF\ ,` jot-- DISTRICT GROUP TYPE CONST. W NE PR CESSED BY dollars ($100)or less.) V v CITY ZIP ct 1 I certify that in the performance of the work for which this permit ems, �r—, /is issued, I shall not employ any person in any manner so as to ✓ ARCHITECT O ENGINEER TEL NO. become subject to the Workers'Compensation Laws. STATISTICAL CLAAYIFI ATION '''APT CONDO Date Applicant ADDRESS CLASS NO, V DWELL UNITS NOTICE TO APPLICANT." If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject to the Workers' CONTRACTOR �J TEL NO. 1` SET BACK YARD HWY PROF,TINE_T WIDTH Compensation provisions of the Labor Code, you must forthwith` VI rJ li FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS 13 LIC.NO. P L LICENSED CONTRACTORS DECLARATION �� P"' �' R3 SIDE s as c: CITY r LIC.CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 \ h1 Ck SEWER MAP .•I'; (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE A NO.OF STORIES NO.OFp FAMILIES Professions Code,and my license•is in full force and effect. 2 1 NEW BK PG , f":-ii License Number GC% j31 Lic.Class DESCRIPTIOrl OF WORK ADD ❑ VALUATION Q Contractor &IiP R,004" Date 'It ALTER El - V ❑ I am exempt under Sec. REPAIR ❑ $ BAP.C.for this reason DEMOL ❑ LDMA P/C# ° W Date: USE OF EXISTING BLDG. URM ❑ - D_ Signature APPLICANT(PRINT)— TEL NO. LDMA Perm# '` Z ❑ I, as owner of the property, or.my employees with wages as Z �` r their sole compensation, will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and ©v itb&IE.Ul1 FINAL DATE Q l ____ ,.,_, _, •,,• Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZA DOUS MATERIAL 2Z :3 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J - '•-"•-f!-' ❑ 1, as Owner Of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY ._ licensed contractors to construct the project (Section 7044, �p �// i_'s,k+? 27 -._ YES ElNO 06 ' Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDINGL` OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH i " "S° ` CONSTRUCTION LENDING AGENCY_ COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR ¢ ° GUIDELINES. (1�� ►V Gl `��(" .:• l L - I hereby affirm that there is a construction lending agency for YES 1:1 NOEL VVVn,�1Y N the performance Of the work for Which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 1 ° 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, N TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS '`;�'�• •• •�^• 3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD./ !^_1 o Lender's Address 3 _ OWNER OR A O o , I certify that I have read this application and state under penalty 0 of perjury that the above information is correct.I agree to comply P.C.FE PERMIT FEE N with all county ordinances and State laws relating to buildingsA3 construction, and hereby authorize representatives of this County ISSUANCE FEE m to enter upon the above-mentioned property for i pection purposes. d a (0 INVESTIGATION FEE TOTAL FEE r •~ $ignalure of plical or A91111 SEE REVERSE FOR EXPLANATORY LANGUAGE , a APPLICATION FOR -BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRES �u a I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS or a certificate of Workers' Compensation Insurance,or a certified 5438 ENCI�,, ITA AVE. copy thereof(Sec.3800,Lab.C.) CITY ZIP TEMPLE CITY 91780 LOCALITY //• Policy No. 27 QA¢-2 79-'I Company STATE FTTNTI SIZE OF LOT NO.OF BLDGS.NOW ON LOT s ❑ Certified c9p9 5 Kele furnished. 01 NEAREST CROSS ST. Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. 45 USE ZONE MAP NO. Date_1 ,/n6($Sicant ASSESSOR MAP BOOK E PARCEL —77150 AG 12 15 0 85883119 SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE $ $ 350-122" WITHIN 1000 FT.OF SCHOOL? YES No (This section need not be completed if the permit is for one hundred ADDRESS MILLER DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100) or less.) 4700 CITY — I certify that in the performance of the work for which this permit E C zIP �i is issued, I shall not employ any person in any manner so as to TElviPL ( ITY CA 917$0 become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO. P STATIS CAL'CLASSI ICAAALLLI N APT CONDO Date Applicant ADDRESS C L Affl6T�— LL ITIaITS NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become Subject to the Workers' CONTRACTOR TEL NO. SET BACK 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. P L 4700 114ILLER DP.. , 735 609931 SIDE LICENSED CONTRACTORS DECLARATION CITY. LIC.CLASS P L 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 & OF STORIES NO.OF FAMILIES SEWER MAP Professions Code,and my license is in full force and effect. 2 2 1 NEW BK PG d License Number 609931 Lic.Class B DESCRIPTION OF WORK ADD ❑ VALUATIONS, , Q Contrac7Y A2J,F. B1JJ-L T Bete 1 q/0 A/Q r; � ALTER ❑ $ ��'z ��� �b cc INC . , 0: ❑ REPAIR ❑ 0 I am exempt under Sec. >> $ B.BP.C.for this reason DEMOL ❑ LDMA P/C# W Date: 12 106Zq 5 USE OF EXISTING BLDG. URM 073 co Signature APPLICANT(PRINT) TEL NO. LDMA Perm# H Z g ❑ 1, as owner of the property, or my employees with wages as $ — Z ACCT. !1 5 their sole compensation, will do the work and the structure is ADDRESS 0— 3303 50.50 not intended or offered for sale (Section 7044, Business and 4700 MILLER DR. , B5 TEMPLE CITY FINAL DATE a Professions Code. _ ) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE g ❑ I, as owner of the property, am exclusively contracting with Q AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY � � ACCT.'7 licensed contractors to construct the project (Section 7044, YES❑ NO M Business and Professions Code.) 3303 739.52 WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING _ OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ITEMS CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR �� \\{ GUIDELINES. rre�Td I hereby affirm that there is a construction lending agency for YES❑ NO tl 'I� TOTAL - 790 ' 02 N the performance of the work for which this permit IS issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING - n 3097, Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, CHECK 790.02 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 SCAOMD. CHANGE .00 o Lender's Address O OWNER OR AGENT 0 1 certify that I have read this application and state under penalty o P.C.FEE PERMIT FEE - { `� d of perjury that the above information is correct. agree to comply �D �(, �/ 0000—Q�31 1..,/ 7/95 N with all county ordinances and State laws relating to building �[tt m construction, and hereby authorize representatives of this County ISSUANCE FEE ?O 3644 1 Attt� 10:21 to enter on the above-mentioned proper nspection� J '0 ; INVESTIGATION FEE TOTAL FEE Sgnat of Appsi—o Da c.7 / SEE REVERSE FOR EXPLANATORY LANGUAGE