HomeMy Public PortalAbout6032 GOLDEN WEST AVE_Building__ `. �
�� . APPLICATION FOR BUILDING E 'WIT IT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION, FOR APPLICANT TO FILL IN BUILDING ADDRESS CTeq/ -
BUILDING ADDRESS 12
hereby affirm that I have a certificate of consent to self insure,
or a cerYficate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) 47
CITY /� ZIP LOCALITY
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InK
Policy No.e.z ����L
Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. (p '�l/ X Q NEAREST CROSS ST.
D-CiIrtified copy is filed with the County building inspection TRACT / BLOCK LOT NO. USE ZONE MAP NO.
department.
y_O ASSESSOR MAP BOOK PAGE PARCEL ,9
Date Applicant PJ G Z. e2Z 62 2 2 SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER Oe QG TEL.N / YES NO
COMPENSATION INSURANCE �'
ADDRESS 514 WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred -)917 /Ual),49, K DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY
dollars($100)or less.) CITY ZIP
I certify that in the performance of the work for which this permit /�/9�'_/G 9/yam` Q �-,�
is issued, I shall not employ any person in any manner so as to AR HITECT OR ENGINEER TEL.NO. /
become subject to the Workers'Compensation Laws. re lG�G e°�%% ¢i��n STATISTICAL CLASSIFICATION APT C0 i
Date Applicant ADDRESS ��L �1 CLASS NO.�DWELL UNITS X
3 /, hwG!/v «,rb 'A
T I
NOTICE TO APPLICANT: If, after making this Certificate•of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR ol TEL.NO. 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. V ADDRESS
/ � LIC.No. PL
`� v �f�� SIDE d
CITY c.cLssLICENSED CONTRACTORS DECLARATION PL -f�, o
I hereby affirm that I am licensed under provisions of Chapter 9SEWER MAP U
(commencing with Section 7000)of Division 3 of the Business and So.FT SIZE NO.OF STORES NO.OF FAMILIES
O:
Professions Code,and my license is in full force and effect. ;:2 � NEW BK PG , ACCT.a U
License Number Lic.Class DESCRI ON OF WORK ADD ❑ VALUATION
LUATION - I- '77�
G?o Z)o
Contractor Date ALTER ❑
REPAIR ❑ y
❑ I am exempt under Sec. $ s'€'1 a
DEMOL ❑ - r
B.&P.C.for this reason LDMA P/C# -?f( i L. ter:
Date: LiE OF EXISTING BLDG. URM ❑ ° 16 i`0 1
Signature APPLICANT(PRINT) TEL.NO_J?1'r LDMA Perm# i 4
❑ I, as owner of the property, or my employees with wages asT �LO �s{
Z I `t_
their sole compensation,will do the work and the structure is ADDRESS L;--t: tz°;,,
not intended or offered for sale (Section 7044, Business and / 0� / 7-0 QLD= � . FINAL DATE �Aq / Q � 1• -
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING O UPANT HANDLE A HAZARDOUS MATERIAL / ✓ i• A{jfli io'.'..
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN
❑ I, as owner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project.(Section 7044,
VES❑ NO❑
Business and Professions Code.) j?IR,y, 03 j 24, 11�.';�=�•;' U;
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
'��' .n,L ,.7 �
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST (J V i 1 AN 10:a• j
FORGUIDELINES.
I hereby affirm that there is a construction lending agency for ves❑ NO❑
the performance of the work for which this permit is issued(Sec. V
I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD
3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES
�. COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING /�,• /
Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
Lender's Address OWNER OR AGENT
o I certify that I have read this application and state that the above FEE P.C.
information is correct. I agree to comply with all county � PERMIT FEE
ordinances and State laws relating to building construction,and e
hereby authorize representatives of this County to enter upon /� ISSUANCE FEE /
the aboyi-mentioned property for inspection purposes. /
INVESTIGATION FEE TOTAL FEE
Sip of Ap Iron°w Apert
SEE REVERSE FOR EXPLANATORY LANGUAGE le / � �i�,(�