HomeMy Public PortalAbout5631 GOLDEN WEST AVE_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING'AND_ SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
BUILDING D RESS
I hereby affirm that I have a certificate of consent to self Insure,
or a certficate of Workers' Compensation'lnsurance, ora certified
Copy thereof,(S/e-c 3800, Lab! C) / CITY C� ZIP LOCALITY
Policy Ne i7�y"� �/� Company"
1'�T� T T SIZE OF L NO OF BLDGS NOW ON LOT
i[ J
� Certified copy Is hereby furnished NEAREST CROSS ST
❑ Ceitified copy Is filed with the county building inspection TRACT BLOCK LOT NO
department A - "i USE ZONE MAP NO
Date l/ Applicant !/�i[��-�� ` ASSESSOR MAP BOOKPAGE PARCEL
SPECIAL CONDITIONS 'I-� •O /
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO
COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOLS YES NO
This section need not be'com feted rf the permit Is for one hundred ADORES /`_
( P P C O •` - ( DISTRICT GROUP TY
pyCONST FIRE ZONE PROCESSED BY
dollars ($100)or less)' " r r
CITY D A f -ZIP -
I certify that in the performance of the work for which this peimit V
is Issued, I shall not employ, any person In any manner so as to
become subject to the Workeirs'Compensation Laws. ARCHIT CT•O ENGINEER - TEL-NO
P STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO a / DWELL UNITS
NOTICE•TO APPLICANT If, after making 'this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become Subject -to the Workers' CONT ACTOR /� r TEL NO- SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith (}A/ o k l/ 0 a(,(`A W1 FRONT
comply with such provisions or this,permit shall be deemed revoked
AD DR S uCP L
LICENSED CONTRACTORS DECLARATION 911 7 SIDE
CITY LIC CLASSl �. P L
I hereby affirm that I am licensed underprovisions of,Chapter 9 ���— SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SQ FT SIZENO OF STORIES NO OF FAMILIES '
Professions Code,and my license is in full force and effect �� / NEW BK PG
a
/�' / J._7 DESCRIPTION OF ORK ADD ❑• VALUATION
License Number ' LIc Class .07'r .C $ a0 a U 0
Contractor Date > ALTER ❑ ✓
❑ I am exempt under Sec W lir REPAIR ❑ $ 0
B&PC for this reason �Ilu 1' �'/ �'��SS• DEMOL ❑ W
LDMA P/C#
Date USE OF EXISTING BLDG URM ❑ -. a a
cr)
Signature APPLICANT(PRINT) ,_ TEL NO LDMA Perm# --_.,•�-� ii -• /(IZ
El 1, as owner of the property, or my employees with wages as Z L___ 1=` r-
their sole compensation, will do the work and the structure is ADDRESS 0 'tL�l=
not Intended or offered for sale (Section 7044, Business and FINAL DATE a
Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL I -Z�'�. 1137 40
!€ i"I +•
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
El I, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE'S FINAL BY
licensed contractors to construct the project (Section 7044, YES 1:1 NO❑ K - -
Business and Professions Code) (`.I �;� o;ati t
• WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING -. i
OCCUPANT REOUIRE_A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR`
GUIDELINES
I hereby affirm that there Is a construction lending agency,for, VES❑ No❑ J,
a the performance Of the Work for WI11Ch this permit IS Issued(Sec _I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE ANDTHE SCAOMD PERMITTING i
3097,Civ C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, �.'j^ i. ( ~• 4•?
TITLE 2,CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS -` , `7 a
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD
EL Lender's Address
O OWNER OR AGENT ••
0 1 certify that I have read this application and state under penalty
Of perjury that the above information IS correct I agree to comply PC FEE PERMIT FEE •// �D
o with all county ordinances and State laws relating to building
mconstruction, and hereby authorize representatives of this County ISSUANCE FEE
to en up tht�bov'mentoperty for Inspection purposes
INVESTIGATION FEE TOTAL FEE
s / "'� '5
l6
SEE REVERSE FOR EXPLANATORY LANGUAGE