HomeMy Public PortalAbout5737 GOLDEN WEST AVE_Building__ ��
76/�63BA CE-4803 4/72 I
DING PERMIT
APPLICATION F R BUILfl
COUNTY OF LOS ANGELES ASSESSOR
DEPARTMENT OF COUNTY ENGINEER MAP BOOK PAGE PARCEL
BUILDING AND SAFETY DIVISIONBUILDING /
ADDRESS
MAKE CHECKS PAYABLE'TO
HARVEY T. BRANDT, COUNTY ENGINEER LOCALITY
FOR APPLICANT TO FILL IN NEAREST _
CROSS ST,
Print ort a only) •' -
DISTRICT NO. GROUP TYPE PRO ESS BY
BUILDING' /y - CONST. -
ADDRESS i �C
STATISTICAL CLASSIFICATION SEWER MA
LOT-NO BLOCK
CLASS NO, DWELL.UNITS BK PG
TRACT US ZONE MAP
NO.OF BLDGS. NO.
SIZE OF LOT NO LO =' SPECIAL
USE OF CONDITIONS
EXISTING BLDG. )
OWNER TE BL G.SETBACK FROM
ADDRESS FR NT PROP.LINE OF (STREET)
�! TY E OF EXISTING SETBACK HIGHWAY + YARD = TOTAL
CITY HIG WAY -WIDTH FROM C.L. --
ARCHITECT O TEL. 1 } _
ENGINEER NO. BLDG,SETB >_
ADDRESS SIDE PROP.LINE OF (STREET) p
TE
YPE OF EXISTING SETBACK HIG AY } Y = TOTAL- U
CONTRACTOR HIGHWAY WIDTH FROM C.L. �
011 U
ADDRES _1;41
C } = I,y
IC. a
CITY l6 CLAS CORNER CUTOFF YES ❑ NO ❑ Z_
CONSTRUCTION LENDER
NAME AND BRANCH SEE PEVERSE SIDE FOR SPECIAL APPROVALS
ADDRESS
SQ FT O OF NO. OF NEW ❑
SIZE STORIES FAMI •IES
USE O - c �1�-(S
STRUCTURE /
AL ER ❑
SIGNATURE OF REPAIR❑
APPLICANT DEMOL ❑
VALUATION $ APPROVALS DAT'p NSP TOR's SIGNATURE
P,C PMT. FOUNDATION: LOCATION '
FEE $ C�' FEE $ �. (J Q FORMS, MATERIALS
FRAME: FIRE STOPS,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACT NG 'BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE- LOCATION,
WITHALL ORDINANCES AND LAWS REGULATING BUILDING CON- GAS VENT, DUCTS
STRUCTI ON I CERTIFY THAT IN DOING THE WORK AUTHORIZED
HEREBY I WILL NOT EMPLOY ANY PERSON IN IOLATION OF THE LATH, INT. '•
LABOR CODE OF THE STATE OF C LIFOR A IN REL T
WORKMEN'SCOMPEN TION INSURAN
/ LAT
SIGNATURE ✓ ✓ OUSE NUMBER COR-
PERMITTEE RECT AND POSTED
ADDRESS ` FINAL Cc r
PLAN CHECK VA A410 cK O CASH PERMIT VA AT ONPCKM 0 CASH
0,2 7 873 MAR N D`•_ - / ,� 2 �7 973 KAR 3 0 1 D�
J A4�^
WORKERS' COMPENSATION DECLARATION
hereby' affirm'that I haver certificate ns consent to self,• APPLICATION :-FOR U I L®I.IV G PERMIT,
insure, or a;ceriificate'`of Workers"Compensation Insurance,
1 g ',
or,a certified copy thereof•(Sec 3800, Lab C )' '- - - � ' ' 11 � _ -
e 1 p 'COUNTY OF LOS'ANGELES BUILDING AND SAF Y -•-
Policy No �;0 5 I / O Company .iTa BUILDING
Certified copy is hereby furnished FOR APPLICANT TO FILL IN. ADDRESS12-
a`CCertified copy-is filed with the county building inspec- BUILDING ;
tion,department ADDRESS �s
Date ����� ��SApplicbnt h�-n.J CITY ZIP LOCALITY c
,CERTIFICATE,OF,EXEMP'ION FROM WORK S' 4- NO OF'BLDGS NEAREST ; ' , `� a',-'j•;'•' "
COMPENSATION INSURANCE` SIZE OF LOT NOW OtJ LOT CROSS S7 ,
(This section need not be completed if the permit-is for one ASSESSOR
hundred dollars ($100)or less ) TRACT BLOCK LOT NO
Y� MAP BOOK y PAGE. PARCEL',`,
OWNER NO b�°1 O�L� USE NE MAF!_,
1-certify that in the performance of the work for-which this, „ �'
permit is issued, I sFSall not employ any person,n any manner .i - f j^ I- 1 SPECIAL q: ,; r
so as to become subject to the Workers'Compensation Laws ADDRESS •/ J ! a b' I CONDITIONS ,d
<,
Date -,Applicant CITY ZIP
NOTICE'T,O APPLICANT If, after;makm This Certificate of ARCHITECT OR _ TEL ;'�- DISTRICT G OUP• TYPE FIRE PROC SSED;BY t
ge ENGINEER NO �^ CONST ZONE.
Exemption;° you should' become 'sublect to the•Workers' _
Compensation prov,isioris of the,Lgb_or,Code, you"must,forth- ADDRESS t`' '� �'�
with -comply with,such'provisions or,,this 'permit, shall be T STATISTICACCCASSIFICATION „ APT' CO JDO
d
deemerevoked ,• e, ' ' ,'''�
, < - r CONTRACTOR r {'y �'�• (Y _ ,
LICENSED CONTRACTORS DECLARATION`',' q T CLASS NO, DWELL UNITS'•'
Thereby affirm that I am licensed under provisions of CFiopter,9 ADDRESS' Q U� NC
'
(commencing with Section 7000)of,DrySEWER'MAP
ision 3 of the Business and LIC ' '- ° •
•Professions,Code, and,my license is m full force and effect' t CITY <!/ < CLASS'C, 3R BK -PG "VALIDATION '
/ SQ FT NO OF NO OF CHECK
License Number bU Class `_3 9 SIZE_ STORIES FAMILIES ONE
�� �i Jrr VALUATION
Contractor pate v— �'� D"� DESCRIPTION OF WORK NEW s /^O � ` f 0
„ ADD J L
I am exempt and Sec t,
ALTER
VL
B 8P C `for-this reason { ' 1 REPAIR $
USE OF: ❑
•Date' EXISTING BLDG DEMOL Z,
Signature f APPLICANT ; TEL ". FINAL_ t
OWNER-GUILDER DECLARATION ,; (PRINT) NO DATE
I hereby affirm that I am exempt fr`om'the Contractor's°License - 5:
Law for the'following reason (Section-7031-5, Business and ADDRESS 's FINAL
Professions Code) N BY_
BUILDING v' 13-67 A'".,
• I, as owner of the property, or my employees with ADDRESS j t
wages as theirsole'compensation;will_do the work and' - - -• ;# e;o
the structure is not intendled of offered'fof sale(Section LOCALITY f
,7044, Business and Frofesstons Code)',', t MOVING. TEL
❑ I, as owner of the rd ert qm exclusive) contractin CONTRACTOR NO <
P P Y. r , s I:• '° 5.9,2 5., ,
with licensed contractors to construct the project (Sec-
5 3f,y.',n ii V ^5 "e:o'o 5 9x�5 61-
tion 7044, Business dnd Professions Code) ADDRESS
REQUIREDTOTA
YARD HWY L SETBACK
CONSTRUCTION LENDING AGENCY , SET BACK PROP LINE ;WIDTH t
I hereby;dffirm that there is a construction lending agency for FRONT
the performance of.t♦i'e work for.,which-this'permit.is issued P•L' .,
(Sec`3097, Gv, G ) t t' SIDE
PL
- F _ :� ,2'2 �k �is
Lender's Name• �� � � T , Ca a` ,, • � v � ,��<. <' ' ` - - .
ADMA`Ref
P C Fee$ Permit Fee'„
Lender's Address
I certify that'I have read this application and state that the Issuance Fee LDMA'P./C'ii
a above information is correct I agree to comply with all Count �'
9 P Y Y Investigation F,ee -' � - � •'' � ., R ••, - a '
o ordinances and.State jaws relatingto building construction,' t
9 : LDMA Perm'ff`
Total Fee
and hereby authorize representatives of this County to enter
m upon thea ve-mentioned propSLtXjar nspectton purposes ,
SEE REVERSE FOR EXPLANATORYLANGUAGE
Signature of Ap ant or Agent 'Date '-• - `,' ,