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HomeMy Public PortalAbout5728 GOLDEN WEST AVE_Building__ Os 76o_639A, CE#803,IREV 6/78) - 4��^ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES - BUILDING AND SAFETY BUILDING FOR APPLICANT TO FILL IN ADDRESS ,Y ' L �- BUILDING ��� LOCALITY ADDRESS ✓ � NEAREST CITY ZIP CROSS ST Z`t U NO OF BLDGS ASSESSOR SIZE OF LOT X NOW ON LOT _ MAP BOOK PAGE I PARCEL // DISTRICT GROUP TYPE FIRE PR SSED BY TRACT 6 BLOCK�J /� ' n _ //{.'y 2 CONST .ZONE OWNE �t/!/ /J `14,:�TNO EL K J 7�p (ice �j% dS STATISTICAL CLASSIFICATION _SEWER M P ADDRESS CLASS NO OC- DWELL UNITS BK '11PG CITY ZIP ARCHITECT OR TEL VALUATION ENGINEER NO ADDRESS BLDG SETBACK FROM TEL FRONT PROP LINE OF (STREET) CONTRACT /�' TOTAL-SETBACK'FROM TYPE OF EXISTING HIGHWAY + YARD = FRONT PROP LINE HIGHWAYI WIDTH ADDRESS -_��fi�i� 0��� LIC + CITY ��'/�S/ CLASS BLDG SETBACK FROM CONSTRUCTION LENDER SIDE PROP-LINE OF (STREET) NAME AND BRANCH TOTAL SETBACK FROM TYPE OF EXISTING HIGHWAY + YARD = SIDE PROP LINE HIGHWAY WIDTH ADDRESS CITY O SO FIC-97 NO OF NO OF CHECK + = N SIZESTORIES FAMILIES ONE ad DESCRIPTION DOFF WORK NEW ❑ PC Fee$ Permit Fee---''J ADD Issuance Fee ' y ALTER -REPAIR ❑ Total Fee USE OF EXISTING BLDG �.ZS/��C7�7�� - DEMOL ❑ 2� APPLICANT / ��// , / TEL b- O BY(SIGNATURE) Q - I'HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE Yu 3 67,3 A THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE. _ # o 0'o ° 0 1 WORK AUTHORIZED HEREBY IW ILL NOT EMPLOY ANY PERSON IN VIOLATION OF U - THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN S COM Z O n PENSATION INSURANCE ' a -?.- 20500 H,-7 �� ° ° O u O O V O U -7 9 p.� 2 NC�6 / 2 APIAL OG'9 m FINA ,� 1 BY` ui s WO�KERS40111111QMPENSATION DECLARATION hereby,affirm That I have certificate of consent to self APPLICATION FOR- B U I L D•I N G, PERMIT ' insure, or a certificate of Workers' Compensation Insurance, • ' or a certified copy thereof-(Sec,`3800"Lab C ) . ��� 9/ . STi3 �FU��J COUNTY OF LOS ANGELES BUILDING' AND SAFETY l Policy No _Company BUILDING �� El, Certified copy is hereby furnishedt FOR APPLICANT TO FILL•-IN ADDRESS [ L " Certified copy is filed'with the•countY building ins ec- BUILDING e,J 7� =tion department " , : - ADDRESS - ' q i1 A /tel �i J /_ /3�.�d/� f G10, CITY ' �/tiJ. G� ` LZIP:- 7! '!o' LOCALITY G7lZ y Date Applicant NO OF BLDGS 4 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT. CROSS ST t " COMPENSATION INSURANCE ' -' ASSESSOR- (This•section•need not be'completed'if the permit is for one' TRACT BLOCK LOT NO MAP BOOK, PAGE PARCEL , hundred dollars ($100) or less ) '' 'OWNER P/�{UE-'_ /'YlAA1 /NJ6� TEL 5���' USE,ZONE OP y I certify,that in the performance of•the,work,for which tl{is permit is issued;I shall not employ any person in any manner ADDRESS -4'2,ZP-6D4 SPECIAL-' CONDITIONS ' so as to become subject to The Workers,Compensation:Laws 0- CITY /­7f,eer e_/T y -ZIP �7/2,00U ) U . ,Date ' Applicant' a ' ARCHITECT OR °_ TEL NOTICE TO APPLICANT, If, after makingthis Certificate of ENGINEER, - NO DISTRICT GROUP TYPE FIRE PROCESSED BY _ O CONST ZONE r Exemption, you,should become•subject,to the tWorkers' Compensation provisions of-the Labor.,Code, you must forth- . r ADDRESS F' +-` :� �GGGt�L�� . .a with.comply with'such provisions or this,'permit•shall .be: TEL STATISTICAL CLASSIFICATION APT CONDO N •' CONTRACTOR deemed revoked - , 11-11 . _ ©.�1_, �,NO"�4J���I z -- LICENSED,CONTRACTORS,DECLARATIONLIC -CLASS NO LDWELL UNITS ' I hereby affirm that I am licensed under provisions of'Chapter 9 ADDRESS •d`�� A4 t v/4K, A UNO Gf�� �� SEWER MAP .(commencing with Section 7000)of Division 3 of the Businessn LIC %�`I�I�CC C- T and Professions Code,and my license is m'full for"ce and effect _ CITY CLASS BK PG VALIDATION SQ FT• NO OF NO OF CHECK,' License Number Lit Class r �� J��f SIZE STORIES FAMILIES ONE - ' ' �Al� "` /O—,.2 fir/ DESCRIPTION OF WORK /4 i�"E-.��� rAe NEW ❑ ' VALUATION ; - • . , • • • - , Contractor_y1��.��� 06ate _ J ❑16m exemptunder Sec SECT/O� To �JUS7!'t� vux_ ADD, ❑ a V� s , ALTER .❑ &' •B&P C for this reason POT- OAJ-- LFi -c'e A, r REPAIR ❑- $ _ USE OF. 'PLtt� w/ T fl -F T6 46W AAts7/a! Dare EXISTING BLDG w DEMOL�❑ Signature APPLICANT TEL T FINAL (PRINT) e .Poop G0 NO.?f� D// OWNER-BUILDER DECLARATION / _ _ DATE '.T B/ m . I hereby affirm that I am exempt from the Contractor's License ' p/�2 ,y��/ � .��� T C �.• Law for the following reason (Section 7031 5, BuADDRESS siness and FINAL` ' .j -Professions Code) ? w PRESENT t By , , •t ,. _ ' ❑ I, as owner of the property, or my employeess BUILDING with _ ADDRESS wages as Their,sole compensation,,will do the work and j ' !n► �j' the structure is not intended or offered for sale(Section LOCALITY 7044, Business MOVING• TEL and Professions'Code ) - - - ' ' r 6 z i ❑ I, as owner of the property, m exclusively contracting '1,l• AL 12'- s aCONTRACTORNO � aJR with licensed contractors to construct the project (Seo- r -. • , [ADDRESS t--• t tion 7044, Business and Professions Code ) s_�HE':t. s�.e_ti• UIRED, TOTAL SETBACK-FROM EXIST- CONSTRUCTION LENDING AGENCY BACK YARD' HWY PROP LINE WIDTH. I hereby affirm that there is a construction lending'agency for NT _ the performance of the work for'vvhich this permit is issued ' (Sec 3097, Civ ,C ) ' a ' iL`ender's NameFD LDMA Ref #ee$ Permit FeeiLender's Address 1 certify that-I have read this application and'state that'pthe Issuance Fee - ' LDMA P/C'# Piloabove information is correct I agree to comply with all County igation Fee / ordinances and State laws relating"to Building construction, Total Fee Co LDMA Perm *#, a and hereby a representatives of this County to enter upon t ove niione roperty for inspection,purposes �3 ' a % � '• 'SEE REVERSE FOR EXPLANATORY LANGUAGE •� _ ,_ - - r -- ignature of Applicant"or Agent , Date