HomeMy Public PortalAbout5801 ENCINITA AVE_Building__ COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDINGyQ�R Ss
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS fid''
or a certificate of Workers' Compensation Insurance,.or a certified 5801 Encinita Avenue
copy thereof(Sec.3800, Lab.C.) Golden Eaq le CITY Temple City 1 ZIP 91780 LOCALITY /
Policy No. - COLD any Insurance Co,
_ SIZE OF LOT NO.OF BLDGS.NOW ON LOT i
>CCer ified copy is hereby furnish _ NEAREST CROSS S
❑ Certified copy is filed with t c my a In p Ction TRACT BLOCK LOT NO.
deg f l l/93 � , AP BOOK8 7- 7-039 USE ZONE MAP No
Data Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
1
CERTIFICATE OF EXEMPTION FROM WORKER owNER_Un Chow 81 T-N574-0050 WITHIN 1000 FT.OF SCHOOL? YES / No
COMPENSATION INSURANCE tl g
(This section need.not be completed if the permit.is for one hundred ADDRESS
dollars ($100)or less.) 2894 Larkfield DISTRICT GROUP TYPE CONST, FIRE ZONE PROCESSED BY
CITY ZIP
is issued,
that h the performance of person
work for which this permit Arcadia 91006 �] `j� "—
is issued, shall not employ any person at any manner so as to cY l'
become subject to the Workers Compensation Laws. ARCHITECT OR ENGINEER TEL NO.
STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS No. DWELL UNITS
NOTICE TO APPLICANT.' If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST '
Exemption, you should become Subject t0 the Workers' CONTRACTOR TEL NO SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith Holland Awning & Shade CO. 18-284-2074 FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC N IL
1205 So..-Mission' Drive 493°869 SIDE ,
,LICENSED CONTRACTORS DECLARATION01 6- �
hereby affirm,that am licensed untlerprovisions of Chapter 9 an-Gabriel L B P L
SEWER MAP
(commencing with Section 7000)of Division 3 Of the Business and SO.FT SIZE NO.OF STORIES NO.OF FAMILIES
Professio11 ns Code,and inCansolicense is in full farce and effect. � '
NEW BK PG - D d
495899 DESCRIPTION OF WORK -ADD ❑ VALUATION O
License NumbE( Lia Class C-61
Contractor Hol aand Awning Date EXp. 7 94 Canvas Awning
g /,Z SO.O0 U
ALTER ❑
❑ 1 a exempt Under Sec'T REPAIR,.-D. $ _. ... . ...... . 0
'"
6&P.C. for this reason - DEMOL ❑ "—•""" V
.. 5E LOMA P/C III
Date: LINT
K081XTP �QG URM ,*❑ - _ IL
Of)_
c _....._
Signature t`yf 1_I •r Z
- APPLICg�T(PRI T) TEL N0. --� LOMA Perm a ----- ---Awning Z _
El 1, as owner of the property, or my. Hoz Femployees with wages as , _ 01 I�] .11„�I
their sole compensation, will do the-work and the structure is ADDRESS - _
not intended Or offered for sale (Section 7044, Business and FINAL DATE
PIOfeSSl00S Code.) WILL THE APPLICANT OR FUTURE BUILDING CCCURANT HANDLE A HAZARDOUS MATERIAL ('1' 3 '
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL To OR GREATER THAN THE J _AC I ar
❑ I, as owner of the Property, am exclusively contracting with < ! ._
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE] FINAL BY. •v 1 �J
licensed contractors to construct the Project Section 7044, '_ `'
Business and Professions Code.) P j ( ves❑ No� � � '--- — I_ .�''=f1? "-"'�I
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING" --,T 1 INS
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR V 1
QUALITY MANAGEMENT DISTRICT ISCAQMDI SEE PERMITTING CHECKLIST FOR . . _. -_V `UIDE ,�}
1 hereby affirm that there is a construction lending agency for YES NI - ue
the performance of the Work for which this permit is issued(Sec. 1.NEUIV 1, )
W I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SGAONADPERMITTING
3097, CIV.C) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. •I'T^ •�11-I
W 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 THESCAOMD.
o Lender's Address -------- ---- '
o I certify that I have read this application and State under penalty 13/31313 t_Ili}1 `l.e% �•
O of perjury that the above infOrmatiOn is Correct. I agree t0 comply PC,FEE / r PERMIT FEE _. /m� " Aly 1,L.
$ with all only ordinances and State laws relating to building Cl D'tJ �� y'U4"1 1 HII a_'°14
m constrn i , antl hereby aut ri representat s Of this County ISSUANCE FEE
to t on the - d property f spoection p ose . S„
a
INVESTIGATION FEE TOTAL FEE /
a w rAem [7
Darrell L. Fksaard, Jr. 5/11/93 SEE REVERSE FOR EXPLANATORY LANGUAGE
WORKERS' COMPENSATION DECLARATION -
I hereby affirm that have-a certificate of consent to self O I��L �LI��Ip� F I��y If,�A M'G �E�Lryrysr�//���
insure, or a certificate of Workers' Compensation Insurance, • ���_ ���� Y ®u V t+ O,UO lJ�����U V V �IS OOIl G11��
or acertified copy thereof (Sec. 380/0, Lab; C.) _ -COUNTY OF LOS ANGELES BUILDING AND SAFETY '
Policy,No.' ( 77L Compony( 'pol.u7 C-c
❑ Certified copy is hereby furnished. .'': - - •FOR APPLICANT TO FILL IN ADDRESS 0 ✓-J +VA
❑ Certified copy is filed with the county but i g
pec- BUILDING
�.tion ddeparrtm)ent P ADDRESS /� ! u _ r-y Al G 'T' '
7.
Dated"pplicant CI L IF
LOCALITY
NO. OF BLDGS. NEAREST _
CERTIFICATE OF EXEMPTION OM''WOR ER SIZE OF LOT NOW ON LOT CROSSST. - -
'` COMPENSATION INSURANCE ASSESSOR
(This�seetion need not be completed if the per it is for TRACT - BLOCK' - LOT NO. - MAP BOOK' PAGE PARCEL
'hundred dollars ($100)or less.) I ' {: - TEL, USE`ZONE ` MAP - r
OWNER d NO- - NO. �V D /-/
o•N
certify that in the performance of the work•for which this '
.perm it,is issued; (shall not employ any person in any manner ADDRESS �; 'L- SPECIAL -
Z% CONDITIONS
so as to become subject to the Workers'Compensation Laws. GG 0
i CITY ZIP 7 /00 -
Date - Applicant - ARCHITECT OR TEL
NOTICE TO APPLICANT: If, after makingthis'Certificate of ENGINEER _ _ NO. .. DISTRICT . 'GROUP TYPE. - "FIRE PROCESSED BY
p CONST. ZONE O
Exemption, you should become .subject to the.Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions.or this permit shall be TEL //�� STATISTICAL CLASSI APT. CONDO. Z
deemed revoked., - CONTRACTOR' SSI L'u Tl LRlt N0.77L'Iy
.LICENSED CONTRACTORS,DECLARATION- p LIC. c CLASS NO ELL NITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1' J TeT0..' NOC2YJY/- '
LIC. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business - 1 ` ,k r
and Professions Code,and my license;is in full force and effect. CITY Cts' CLASS G— �o BK PG,
VALIDATION
2N/,// (� SQ. FT: NO, OF NO. OF "CHECK
License Number, 7 7 Lic. Class C—/6 SIZE I STORIES FAMILIES ONE _
Q yn� Q I - - VALUATION . .
Contractors`���• Date / �Q-. �•- DESCRIPTION OF WORK NEW ❑ s �j�� t•Q -
i - - cJ ,
Elam exempt under Sec. !QC' P!r F rd E.� r ) L.1.SST/} ADD E) D L .
- - _ - - ALTER ❑
B.BP.Cr for this reason REPAIR E-1 $
_�kte: . USE OF
EXISTING BLDG' DEMOL"❑ -
• Signature - APPLICANT \ - ` TEL l {I`�_I FINAL -
ER-BUILDS DE RATION '(PRINT) Fr") w ti L NO DATE
hereby affirm that am exem fr the Contractor's License - ,.� /J -
- Law for the following reason ( act n 7031.5;-.Business and ADDaESS (� �L �D l,n FINAL - -
ProfessionsCode): - FADDRESS
. . - -. . ". By..,•.
❑ I, as'owner of the property, or m employ'
m to ees with - -
P P Y Y P Y -
•" wages as their sole compensation;will do the work and - - D the structure is not intended or offered for sale(Section - !
.. TEL. t
7044, Business and Professions;Code.) - .. -
❑ I;as owner of the property, am exclusively contracting CTOR NO. '
with licensed contractors tc construct the project.(Sec- t - -- - - - '
tion 7044, Business and Professions Code.) -
REQUIREDTOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY' PROP. LINE WIDTH
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.). SIDE
P.I.
Lender's Name
LDMA Ref.
,.- P.C. Fee$ Permit Fee ✓ ✓ -
3 Lender's Address '
a certify that have read this application and state that the Issuance Fee l LDMA P%C'N ..
8 above information is rrect. I agree to comply with all County jnvestigagon Fee
R ordinance and Sta ws relating to building constructions Total Fee LDMA Perm. A
a and her By authors a pre$ tatives of this County to enter
up n e abov m Mi ned party for inspection purposes.
a ,
Z SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of an or Agent Date _ - -
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self O O `l/�/,/L�.�\517 �EI��U�� I��} �r�y �,r��L �EI��Ip��(/�� D
insure, or a certificate of Workers.Compensation Insurance, A,1PPU, C?u, Tv tF M V U OPR LkY���®�N, G PERMT ,
'
or.a certified copy thereof (Sec 3800, Lob..C.) - 'COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
-
Policy No. Company
BUILDING Q t
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN - ADDRESS U0 -r>J1[jn
❑ Certified copy is filed with the county building inspec- gDDREING
SS
tion department. ..
CITY'. . �J1�I'I l I- ZIP - I' LOCALITY
i,... . ..
Date - Applicant L - t� NO. OF BLDGS. _ NEAREST ^I y a -
• "CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 10 U S, NOW ON LOT 2 CROSS ST. �'V/6N 01'a 1 ,
COMPENSATION INSURANCE _ ASSESSOR _
-- _ _ MAP-BOOK PAGE PARCEL
(This section need not be less.) ted`tf the permit it for one TRACT BLOCK LOT NO.
hundred dollars ($100) or less.) - TEL
OWNER rr i') Gi n.I IK IJ ^ j -74 6• USE ZONE OF
I certify that in the performance of the work for which this
SPECIAL
permitlis issued,] shall not employ any personin any manner ADDRESS I Q G'
_
seas to become subject to the Workers:Compensation Laws. _ CONDITIONS O
•� - CITY 'V C44 � - ZIP �� - . _ , U
-Dote - .Applicant ARCHITECT OR - TEL. ./-- '-sOf
NOTICE TO APPLICANT:- If, after making this Certificate of ENGINEER url NO. 7 00 :DISTRICT WGOUP" CONST. FIRE E PROCESSED BY O
.,Exemption, you should become subject to the Workers' • p r C� V _ ; e�'JJ C U
Compensation.provisions of the Labor Code, you must forth- ADDRESS 7i -1 �G✓ lP -t ,..) 6/, �G�Ke-GGA! aa_
with comply with such provisions or this permit shall be - TEL STATISTICAL CLASSIFICATION - APT. . CONDO. h
deemed revoked. CONTRACTOR N �/'�p a Z
LICENSED CONTRACTORS DECLARATION L'ZZ 72w �� - �_� CLASS NO.___S�nNVR- UNITS
I hereby offirmthat I am licensed under provisions of Chapter 9 ADDRESS 6
MAP
LIC.
(commencing with Section 7000)of-Division'3 of the•Business U � SEWER '
and Professions Code,and my license is in full force and effect. M CITY ,CLASS BK. PG. - VALIDATION
SQ. FT.I j NO. OF /,' NO. OF CHECK
.License Number Lic, Class- SIZE V STORIES FAMILIES ONE
/ 'VA TION
Contractor - Date DESCRIPTION OF WORK 1 Sf NEW .
❑I am exempt under Sec. U - l Q/I .Orn yLVW - ADD _ ❑ - 1 D - "_" _
_ .... _ .. _._ ,ALTER ❑
B.&P.C. for this,reason" - REPAIR ❑ .S.
- - Date: USE.OF... .. -. - ..
EXISTING BLDG. DEMOL ❑
Signature - -� _APPLICANT / /• TEL. /
g OWNER-BUILDER DECLARATION (PRINT) r U G N Q-1 - NO. 1400` FINAL
ATE
I hereby affirm that I am exempt from the Contractors License V Z-�I
pw for t 'following reason (Section 7031.5, Business'and ADDRESS Z ! ,"r/s fQ�U - !^t ' DNAL �- • 'I
P of ns Code): . F PRESENT ,°!!'- �. �-' By _ n
11
BUILDING ti / .r 2 � ) y
C as owner of the property, or my employees with ADDRESS _ q 7 -
✓�/ wages as theirsole compensation will do the work and LOCALITYpc•�, (,1 r),h !.-3:17 ft
the structure is not intended or offered for sale(Section P .� 1
7044, Business and Professions Code ) MOVING - - - •TEL.
Imo/ CONTRACTOR NO.
LJ I, as owner of the'property, am,excluswely contracting ��•� .I. r
with l icensed-contractorsto construct.the project-(Sec- ADDRESS ' S O J CIIL i
tion 7044, Business and Professions Code.) - " l//• �i,�, 1 \ •,_ i I
REQUIRED - TOTAL SETBACKFROM.'• EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARDHwv PROP. uNE wioTH I T. '
hereby affirm that there is a construction lending agency forFRONT , ' _ _ - 1 ,u 1 j s• � II'r
the performance of the work for which this'permit isissued P.I. I
(Sec. 3097, Civ. C.) /y/y �(/� SIDE I ' N
CSe�1 CI✓Vl 9R{L� P:L M V,11 � /ir 1i1 Jl SitiT r tj
'Lender's Name d '` /!
$ Pr rT !K�'( - —/ 7y ` LDMA Ref.•N�/
P.C. Fee$ /' / Permlt Fee �� .3�-'ter 1 P' 1
Lender's Address �j y D _
a f certify that 1 have read this application'and state that the Issvonce Fee' cs /� LDMA P/C'N
Sabove information is correct..)agree to comply with all County Investigation Fee �/(/X�i�( .. -
d - ordinances and State laws relating to building construction, Toto]Fee 1/'-/�J_ �3, LDMA Perm. q
m and hereby authorize representatives of this County to enter _
^ 'upon t _ bove-me ti ned prop-rty for inspection purposes. -
a6- (" Z SEE REVERSE FOR EXPLANATORY LANGUAGE
igna ure of.Applic or Agent Dote ,_