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Home My Public Portal About5930 GOLDEN WEST AVE_Building__ -' al pUCAMON [COIR BU LONG PERI T 91 COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDADDRESS �. ` or a certificate of Workers' Compensation In nce,or a c ed 4 VL! copy thereof(Sec-� ab CITE - zl /• O � LOCALITY Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. ?' NEAREST CROSS ST. _ okcUSertified copy is filed with the u buildin ion TRACT BLOCK LOT NO. U_/O o d �✓r_� depart ent. E ZONE MAP NO. ASSESSOR MAP BOOK PAGE PARCEL Date �'� pplicant SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWE o COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? YES NO This section need not be completed if the permit is for one hundred ADD E ( P p � DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100)or less.) I certify that in the performance of the work for which this permit ZIP >0�O is issued, I shall not employ any person in any manner So as t0 ARCHITECT OR ENrINEER TEL NO. become subject to the Workers'Compensation Laws. - STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS _. CLASS NO, DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate ofREQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become Subject t0 the Workers' CON ACT0 TEL NQ„/� D SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith ((XX.��!!//�� FRONT comply with such provisions or this permit shall be deemed revoked. AETDRESS IF LIC 0. PL 4 11L^LICENSED CONTRACTORS DECLARATION SIDE IT � O g� LIC. SS P L I hereby affirm that I am licensed underprovisions of Chapter 9rh V — SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.F .SIZ NO.OF STORIES NO.OF F MILIES Professions Code,and my license is in full force and effe (? t_' NEW ❑ BK PG a License Number Lic.Class DEARIPTION OF WORK ADD ❑ VALUATION O '�' O Contractor Date - ��1 ALTER ❑ $ �0 P �+ ❑ I am exempt under Sec. REPAIR ❑ $ 0 BAP.C.for this reason (� j� /� DEMOL 1:1 t; P/C# W Dat u EEXISTIN BLDG. URM ❑ 0- Signature APp NT(PRINTj LDMA Perm# - z ❑.I, as ovine of the property, or my employees with wages as Q ZOf-)1-V`- their sole compensation, will do the work and the structure is R DATE •. not intended or offered for sale (Section 7044, Business and FINAL� � Professions Code.) ' -zi m i l WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE - ❑ I, as owner of the property, am exclusively contracting with TS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY �. Es p; —n—m licensed contractors to construct the project (Section 7044, :;,:L 137 —; m Business and Professions Code.) VES El No WILL THE INTENDED USE OF THE 9UIDLING BY THE APPLICANT OR FUTURE BUILDING ; 7!-}L'•�: f,!e;'o4'-i OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR A/� / :•,� s :-.. GUIDELINES. -'IG I hereby affirm that there is a construction lending agency for YES 1:1NcVA ) - a the performance of the work for which this permit is issued(Sec. IHAVE RE THE ZA DOUS MATE ALS INF ATION UIDE AND THE SCAQMD PERMITTING 3097, Civ.C. - - N ) CHECK 'T U ERS NO MV REQ EM UNC THE LOS ANGELES COUNTY CODE, TITLE ER 2. SECTIONS 2.2 . 0 HROUG 2.20.140 CONCERNING HAZARDOUS Lender's Name MAT R G AND FOR OBT N ty��,�p IT FROM HE SCAQMD. ,r CL A_f_:' _ IIFI�S`a9:f o Lender's Address O - O ERS A NT o I certify that I have read this application and state under penalty 4 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE o with'all Unty ordinan S and State laws relating to building ro A to , and here authorize representatives of this County ISSUANCE FEE �� 0 ,•• ':,,,;� a:,�;,�;`` cu n th o e entioned property for inspe do purposes. m INVESTIGATION FEE TOTAL FEE � r SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT it COUNTY OF LOS ANGELES . BUILDING AND SAFETY BUILDING ADORE FOR APPLICANT TO FILL IN WORKER'S COMPENSATION DECLARATION � � hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRF,SS_ � or a certificate of Workers'Compensation Insurance,or a certified ��` .� copy thereof(Sec.3800,Lab.C.) CI Cl ZI p 7 LOCALITY Policy No. Company IZ OF LOT NO.OF BL GD S.NOW ON LOT ❑ Certified copy is hereby furnished. j p / NEAR-ESTROSS ST. ❑ Certified Copy is filed with the county building inspection TRACT BLOCK LOT NO. ZAS department. I USE ZONE MAP NO. ASSESSOR MAP BOOK PAGE PARCEL Date Applicant SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' �,iOWNER O%� �� TEL.NO. YES NO COMPENSATION INSURANCE ice WITHIN 1000 FT.OF SCHOOL? ADDRESS (This section need not be completed if the permit is for one hundred DISTRICT GROUP TYPE CO ST.' FIRE ZONE P OCESSED BY dollars($100)or less.) CM ZIP 0.3 3- I certify that in the performance of the work for which this permit SnJ cc`JJ�� is issued, I shall not employ any person in any manner so as to ARCH ECT OR ENGINEER TEL.No. become subject to the Workers'Compensation Laws. 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 ShOUId become Subject t0 the Workers' C N`RVCgR F�LfNO. s , SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith [� FRONT comply with such provisions or this permit shall be deemed revoked. A DRESS ,(// LIC.NO. PL "_ —f// SIDE LICENSED CONTRACTORS DECLARATION CITYr, � LIC.CLAs PL 0 1 hereby affirm that I am licensed under provisions of Chapter 9 A9 9&U-0 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ. .3) NO.OF STORES NEW ❑ BK PG NO.OF FAMILIES O Professions Code,and my license is in full force and effect. V �L DE CRIPTION OF WORK (X1 V LUA ON /1� , W License Number Lic.Class r ®® ADD T� C/ N Contractor Date ALTER ❑ Z ❑ I am exempt under sec. REPAIR ❑ B.&P.C.for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ Signature APPLI ANT(PRINT) f oTEL.NO. LDMA Perm# Z i El 1, as owner of the property, or my employees with wages as D�� z)A� Q � '—: p �•— a their sole compensation, will do the work and the structure is DDREs3 F AC (=s' not intended or offered for sale (Section 7044, Business and '" n $d FINAL DATE :IC L-7cq PfOfeSS10r1S Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL. j ,r I, as owner of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN ; 1 I j EB it Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? F1"J licensed contractors to construct the project.(Section 7044, YEs❑ No❑ �) ""' Business and Professions Code.) 1 AL 93= 63 WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING - s.,a �...� OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CHECK 7•.i= -` CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. a I hereby affirm that there is a construction lending agency for YES 11 NO El t•HNNIGE �'I the performance Of the work for which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATI IDE AND THE SCAQMD 3097,CIV.C.). PERMITTING CHECKLIST.1 UNDERSTAND REQUI TS UNDER THE LOS ANGELES m. CO CODE,TIT 2,CH PIER 2. TI N I. THROUGH 2.20.140 CONCERNING i t` 'ti + w '} m Lender's Name H R )US MA L R ORTI DF OBTAINING A PERMIT FROM THE SCAQMD. Ej0�'�i_1•.30 if Vf�E? l(LLenders Address -E A s t _ i o 1 certify that I have read this application and state that the above P.C.FEE PERMIT FEE information is correct. I agree to c ly with all county ordinances and State laws relating to ildi construction,and 6 ¢. her authorize representatives of Ois C n to enter upon ISSUANCE FEE a7;q entio prop rty for' cti p rposes. i O a INVESTIGATION FEE TOTAL FEE � e C.-.bbr A� I Lf UAte SEE REVERSE FOR EXPLANATORY LANGUAGE, WORKERS' COMPENSATION DECLARATION } a r Ql�itereby affirm that I hla�v�F 1��,,.�,certif cote of consent t¢ self L W T I - F®R' BUILDING- PERMIT insure, or a certificate of_1,o�'ers' C�ompensdtign'Insurance, • �I or d cerlified copy fjTreof (Sec. 3800, Lab. C. � ` y - COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING �v 7z � ADDRESS �/ dlf/ ❑ Certified copy is filed with the county building inspec- BUILDING J tion department. ADDRESS �� / c Date Applicant CITY , ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' I O. OF BLD S. NEAREST "�,I ' COMPENSATION INSURANCE SIZE OF LOT, NOW ON LOT CROSS ST. 66..�� (This section need not be completed if the permit is for one ASSESSOR hundred dollars ($100) or less.) TRACT BLOCK y �� LOT MAP BOOK PAGE PARCEL TEL USE ZONE MAP �•�y+1 I certify that in the performance of the work for which this OWNER . P /NO.' NO. permit is issued, I shall not employ any person in any mannerSPECIAL so as to become subject to the Work Com ensation S. ADDRESS p CONDITIONS CITY ZIP Dat"TOAP Appli t6 ARCHI ) I f ay /� r TE .j e;NOT: If, after m n th' erti ica of ENGINEER 8�Q/ V NO�I�P DISTRICT GROUP TYPE FIRE PR CESSED BY Exe , ld ecome subje t to a War a s' CONST. ZONE Compensation provisions of the Labor Code, you must fo ADDRESS v with comply with such provisions or this permit shall be TEL. STATISTICAL CIASSIFICA ON APT i. . deemed revoked. h CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 21 DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK PG 31 VALIDATION y: SQ. FT. NO. OF NO. OF CHECK 1 0. License Number Lic.Class SIZE STORIES FAMILIES ONE ) �, J,I VALUATION z U DESCRIPTION OF WORK j0 �ti� a NEW O,IO' _ +cO Contractor Date .. , ADD V ❑ I am exempt under Sec. v ii • t fl, ALTER ❑ B.BP.C. for this reason ...t� S /b [l� EPAIR ❑ $ AA USE OF Date: DEMOL ❑ -�_ XISTING BLDG. Signature APPLICANT / � ��hd NO. 1 FINAL PRINT OWNER-BUILDER DECLARATION DA - I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FIN Professions Code): PRESENT BY BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044,'Business and Professions Code). MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. - with licensed contractors to construct the project (Sec- ADDRESS " tion 7044, Business and Professions Code). _ REQUIREDTOTAL SETBACK F CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT 1 '3 ; the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.), SIDE ( !": C. P.L. �. Lender's Name �q `-� - .. 'V'3• �� t m P.C. Fee$ Permit Fee LDMARef. II V Lender's Address 3 $ I certify that I have read this application and state that the -] Issuance Fee Lid• LDMA P/C a above information is correct. I agree to ply with all County Investigation Fee -- -•_ S ordinances and State laws relating o b ilding construction, ` ��3• 75 6 - Total Fee 1 LDMA Perm. and eby auth rize representati s o this County to enter up t e obove m n ne pr ��,f i sepurposes ction r L a �A SEE REVERSE FOR EXPLANATORY LANGUAGE ln.turpf ppti c S nt or nt Da r WORKERS' COMPENSATION DECLARATION insure�ereCbor a certif carte of WorkersrlComTpensat oe of n Insurancnt to ef APPLICATION FOR BUILDING` PRM I T or a certified copy thereof (Sec. 38000, Lab. C:) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. ill Company 7I'/� kivA BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS � Certified copyis filed with the cou ty b ing ins p BUILDING ,(� /�-O tion de artment. ADDRESS V � '� C, zipI ` Dare G Applicant CICITYG0 LOCALITY ZIF NO. OF BLDG5. NEAREST CER IFICATE OF EXEMPTION FROM W RKERS' SIZE OF LOT NOW ON LOT ` CROSS S7. COMPENSATION INSURANCE (J (This section need not be completed if the'permit is r one ASSESSOR TRACT BLOCK�� LOT NO. �d MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL. �j �} J �T OWNER C (b NO. 5 '(l Y USE ZONE O. /0/D 1 certify, that in the performance of the work for wh' h this, �i { �. �f SPECIAL >_ permit is issued, I shall not employ any person in an manner ADDRESS 1t�.1 {1 + k-'� CONDITIONS ( CL so as to become subject to the Workers' Compens ion Laws. O CITY LX4 ,4 VA Sh 6C W4, ZIP U Date Applicant ARCHITECT ORTEL. NOTICE TO APPLICANT: If, after makingtheCertificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY Q Exemption, you should become subject the Workers' .�) �dd CONS, ZQ(tE U, Compensation provisions of the Labor Co , you must forth- ADDRESS ✓�{ a with comply with such provisions or t is STATISTICAL CLASSIFICATION APT. CONDO. N p y p permit shall be �"TEL yy�� Z ; deemed revoked. CONTRACTOR &NO. C. _ LICENSED CONTRACTORS D LARATION LIC. CLASS NO. v�l DWELL.UNITS ADDRESS � . NO. r, I hereby affirm that I am licensed unde provisions of Chapter 9 SEWER MAP •1, (commencing with Section.7000)of ivision 3 of the Business ��`` �, (� LIC. y� and Professions Code,and my licens is in full force and effect. CITY �y1/ e/ C�^�C. CLASS 1'7' BK PG VALIDATION ,,��JJ � SQ. FT. NO. OF NO. OF CHECK License Number tq Lic. Class— � SIZE STORIES FAMILIES b ONE 1,�} VALUATION Contractor W�j 4 S DESCRIPTION'OF WORK �J r NEW 1 Contractor Date E Elam exempt under Sec. t� v' ADD ❑ pool ALTER ❑ c B.&P.C. for this reason �7 S ' 41 LIE—k" REPAIR ❑ $ Date: USE OF ` EXISTING BLDG. DEMOL ❑ Signature �( APPLICANT ��p TEL, OWNER UILDER DECLARATION (PRINT) W �►/ NO.2�'y�d FINAL DATE j I hereby affirmthat I a exempt from the Contractor's License Law for the following reason'(Section 7031.5, Business and ADDRESS Z� G FINAL Professions Code): J PRESENT By ❑ I, as owner of the property, or m employees with BUILDING r P P Y� YADDRESS – wages as th it sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY •(� _ 7044, Business and Professions Code.) MOVING TEL. I CONTRACTOR NO. _ ❑ _ I, as owner of the property, am exclusively contracting y I"3s y„ �-y with licensed contractors to construct the project (Sec- ADDRESS _ tion 7044, Business and Professions Code.) K / REQUIRED TOTAL 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 '' l't }– '`=` the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ, C.,). SIDE % P.L. Lender's Name ";"t' J�{":_I �� •• " m � LDMA Ref. # �---' - P.C. Fee$ Permit Fee '- Lender's Address r o I certify that I have read this application and state that the Issuance Fee LDMA P/C# r above information is correct. I agree to comply with all County Investigation Fee 6 ordinances and Stat laws rel ' g to b ilding construction, Total Fee 0p LDMA Perm. # and reby u or' represent t of this County to enter ' up n e v - Hone Q '1d pro ty for inspectio pores. a -1 wur SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Apvpllcant or ent 9rte WORKERS' COMPENSATION DECLARATION insure,borairrn afcertif certificate of Workers' Compensation Insuran of A P P L I CAT I O 1 FOR BUILDING, PERMIT or a certified top thereof (Sec. 3800, Lab. C.) //JJDp t ere LAS COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Policy N �Company BUILDING �7( Certified copy is hereby furnished.. FOR APPLICANT TO FILL IN ADDRESS ::!fp Jhl Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS CITY 77Z7HPeAEZIP LOCALITY DateApplicant . OF BLDGS. 67 CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT NEAREST CROSS ST. COMPENSATION INSURANCEASSESSOR (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.) . TEL. OWNER, NO. USE ZONE MAP _ NO. �� I certify that in the performance of the work for which this permit is issued; I shall not employ any person in any manner ADDRESS � �^ /(', 3 SPECIAL a """✓✓✓ ### CONDITIONS so as to become subject to the Workers' Compensation Laws. / O CITY — ZIP Date Applicant ARCHITECT OR TEL 0 NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY "`�CONST. ZONE 0 Exemption, you should become .subject to the -Workers' (/ U Compensation provisions of the Labor Code;you must forth- ADDRESS �e /� �;:- d with comply with such provisions or this permit shall be TEL 5jaSTATISTICAL CLASSIF ION T. CONDO. N deemed revoked.: P CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION Z LIC. q CLASS NO. DWELL.'UNi ' ° ADDRESS I hereby affirm that i am licensed under provisions.of Chapter 9 SEWER MAP '� -•-"-'r - •-_ _- .(commencing with Section 7000)of Division 3 of the Business n /� ,/ LIC. CITY Q /� T�-CG► CLASS —f i and Professions Code,and my license is in full force and effect. BK PG. VALIDA 16N 7 ,y SQ. FT. STONO.RIES OF FA OF CHECK License Number Z4� lic. Class tl / SIZE STORIES FAMILIES ONE ti il: VALUATION DESCRIPTION _ /C DESCRIPTION OF WORK NEW t Contractor Date / � ;�'=•, 4111 a+- ` ADD ❑ Vii%"i at ❑I am exempt under Sec. ALTER ❑ '" '•..!_iF.' B.&P.C. for this reason �f14,654,9a _ REPAIR ❑ �' Date: USE OF 3s —+'[_, _t''"'.6' +•- EXISTING BLDG. DEMOL ❑ i 't `gym. Signature_ APPLICANT TEL. FINAL1 M t Ls"rL (PRINT) NO. OWNER-BUILDER DECLARATION DATE;-�-.3o I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT' By r_, '•1 BUILDING El 1, as owner of the property, or my employeeswith ADDRESS wages as their sole compensation,will do the work@and LOCALITY the structure is not intended or offered for sale(Section ' 7044, Business and Professions Code.) MOVING TEL. ' CONTRACTOR❑ NO.I, as owner of the property, am exclusively contracting y I II r'I i with licensed contractors to construct the project (Sec`- ADDRESS •z, tion 7044, Business and Professions Code.) t -_ � =.r REQUIRED TOTAL 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 Lender's Name. q 4 op m \ �' �� yQ• 6 O LDMA Ref. # P.C. Fee$ Permit Fee Lender's Address o I certify that I have read this application and state that the .. Issuance Fee d LDMA P/C# Pool 8 above information is correct. I agree to comp) with all County Investigation"Fee d ordinances and State laws relating to builling construction, Totol.Fee LDMA Perm. # a and hereby authorize representative of Th' County to enter upon th ove-merytipned r er for in pection'pu7oses. c � ! SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Applicant or Agent-- Date -