HomeMy Public PortalAbout5338 GOLDEN WEST AVE_Building__ 7GA538A CE#803�,-S I APPLICATION FOR BUILDING PER T
COUNTY OF LOS'ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
B=ING AND SAFETY DMSION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN SUPT OF BUILDING CROSS ST.
DISTRICT NO. GROUP TYPE SSED BY
FOR APPLICANT TO Ml IN �i Q CONST.
BUILDING ` �'n /� STATISTICAL CLASSIFICATION SE ERMAP
ADDRESS JJ -�d (�0 I'•
CLASS.NO DWELL UNITS
LOT NO Q Gt BLOCK WATER
CERTIFICATE NOT REQUIREDcx RECEIVED
TRACT ggMAP' / HIGHWAY STATE MAJOR SECOND, LOCAL
SIZE•OF LOTJ V /!7/,�,, I NOW ON LOTS O U9 ZONE SPECIAL LE)
USE OF PPS~ CONDITIONS
EXISTING BLDG
' - TEL
OWNER /, NO . BUILDING YARD HWYSETBACK WIDTH
R T,NAME EXIST
ADDRESS �I Ve C
FRONTARCH
ENGINEER
OR TEL. 1jY P L
ENGINEER E A76 NO SIDE
ADDRESS Lrti `AjQ P L la
CONTRACTOR WyI IQ N
TEL INSPECTI/O��N RECORD /7 Q
ADDRESS l�7
DESCRIPTION OF WORK
w
A�a� �/z,"
NE ADD ALTER REPAIR DEMOLISH / / / VJ
FT. v NO OF NO OF Z
IZE STORIES FAMI 1 /
USE Or /--o
STRUCTURE
SIGNATURE OF ,
APPLICANT
VALUATION$ +oa
T� �y.�7 APPROVALS DATE -INSPECTOR'S SIGNATURE
FEE $ � FEE PMT $J r FO FORMS,MATERIAAITS
FRAME 'FIRE STOPS, •,;Y r CO'
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING, BOLTS
AND STATE THAT THE ABOVE`IS CORRECT,AND AGREE TO COMPLY FURNACE LOCATION,
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING- GAS VENT DUCTS r,:
BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE WORK vv((
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH, INT.
TI D N OF THE LABOR CODE OF THE STATE OF CALIFORNIA �FLAT-
INTO-WORKMEN'S COMPENSATION INSURANCE LATH,EXTSIGNATUR
NUMBER
PERMITTEEE OF v/ HOUSE
AND POS EDD
ADDRESS FINALIn
CLYDE N. DIRLAM, PRINCIPAL ST RAL ENGINEER
PLAN CHECK VALIDATION cK M.O. CASH' PERMIT VALIDATION cK. m.o. cAsH
2 D '2 5 .5
L- 'o 4 1 5 7 GCI' 1 -3 1 D 5 4,.0 0
, . APPLICATION FORS BUILDING PERMIT_
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS 53 3 e 6401 P�
I hereby affirm that I have a certificate of consent to self i6sure, BUILDING A DRE S� o N
or a certificate of;Workers' Compensation Insurance,or-a certified CIT ZIP
copy there 2; 'C,'3800,Lab C) / _,, J /L C' LOCALITY 1�
Policy No 957�l1 Company )
_ SIZE OF LCT NO OF BLDGS NOW ON LOT Ll
❑ Certified copy Is hereby furnished' 'NEAREST CROSS ST
❑ Certified Copy Is filed w th the co ty budding Inspection TRACT BLOCK LOT NO U l 1
- ,USE ZONE MAP NO
,epartm7t , -
c ASSESSOR MAP BOOK PAGE PARCEL n
'Date 5 3 Applicant �G '
"SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER
�7 J TEL N vEs No
_ C
COMPENSATION INSURANCE / WITHIN 1000 FT OF SCHOOL?
(This Section need not be completed if the permit is for one hundred ADDRESS 1�s5�
DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
.dollars ($100)or less) _
CITY ZIP
,!,certify that 1n the performance of the work for which this permit
is Issued,•I shall not employ any,person In any manner so,as to ARCHITECT OR ENGINEER TEL NO - J
become subject to-the'Workers'Compensation Laws - STATISTICAL CLASSIFICATION APT CONDO
•Date :Applicant ADDRESS CLASS No . _ DWELL UNITS 1
NOTICE TO 'APPLICANT If, 'after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become-'Subject Ito ' the Workers' 'CONTRACTOR �1� TEL NO SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions,of-the Labor Code,'you must forthwith fix(, /T` FRONT
comply.wdh•such provisions or this permit shall be deemed revoked ADDRESS / LI NO P L
• 11 �7ljj�,. �s��(O
SIDE,
LICENSED CONTRACTORS DECLARATION CITY ,1 LIC CLASS P L
I,hereby affirm that I am licensed underprovisions of•Chapter 9 U��� SEWER MAP
(commencing with Section.7000)of Division 3 of the Business and, SQ Fr SIZE NO OF STORIES NO OF FAMILIES d
ofessions Code,and m license Is in full force and effect NEW ❑ BK PG ; O
V` !� U
V ense Numbe�j � Lic Class `� 3'7 DESCRIPTION OF WOR ^^ � l ADD' ❑ VALUATION
' ` Contractor K 7p �/� zJT� J ALTER ❑ $
❑ I am exempt under Sec 44'� (/ /J G REPAI lyr_r, ,g O
B&PC for this reason �5�'�� ov+r DEMOL ❑ LDMA P/C# J--_j U
Date USE OF EXISTING BLDG r/tiN 4 URM ❑
9
Si nature APPLICANT(PRINT) TEL NO - LDMA Perm# TOTAL
❑ I, as owner o e property„ of my eriTployees with wages,as r
their sole compensation; will do the work and the structure is ADDRESS 0 ':: CK j_,4 25
not Intended or offered for sale (Section 7044, Business and FINAL DATE Q n _
Professions Code) - WILL THE APPLICANT OR'FUTURE BUILDING'OCCUPANT HANDLE A HAZARDOUS MATERIAL
f� #jaE
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 111
❑ I, 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,
YES El No❑
Business and Professions CodeWILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING +• �'
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION D) MODIFICATION FROM THE SOUTH
COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR '`/Jr^j .i._f l� rd`��CONSTRUCTION LENDING AGENCY 61�
C�I��,,I,�^,
GUIDELINES
I•hereby affirm that there Is a construction lending agency for 'YES El ' NO 1:1
cv the performance of the work for which this permit Is issued(Sec
p1 I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING
N 3097,Civ C) CHECKLIST I UNDERSTANDWY 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 SCAQMD
0 l-ender's Address
O ONNER OR AGENT -
o I,certify that I have read this application and state under penalty
C P C FEE PERMIT FEE
of perjury that the above Information is correct I agree to comply
with all county ordinances and State laws relating to budding
CORSt Cti n, and hereby aut onze representatives of this County ISSUANCE FEEco
-
� to-e er u n,the ab ve- d property for ins e�cG7on purpo _ (p 'T(/ •
a /��
(0 INVESTIGATION FEE � TOTAL FEE. `�
AOW1 a Agee owe "� ♦ef-
SEE REVERSE FOR EXPLANATORY LANGUAGE