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HomeMy Public PortalAbout6036 GOLDEN WEST AVE_Building__ APPLICATION FOR BUILDING PERMIT �1 COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDR56, BUILDING AD R �pG DEQ�� /_ 03 I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) _ CITY /� ZIP 2 ��fYf P G E Ci/ LOCALITY _ PolicyNo ��/lQ' 0 Compa �� C SLG— ee/ SIZE 0 �T O.OF BLDGS.NOW ON LOT Certified copy is hereby furnished. hn `�/ ((77l�// D NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. oo.����� n �A��� USE ZONE MAP NO. ♦ 4 Date A licant G rCtx G C✓ ASSESSOR MAP BOOK PAGE PARCEL PP a3 � ,,,G Z G Z L SPECI ONDITIONS ^ CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER µ Al NO. $✓/ �� -���y�' -'��/ WITHIN 1000 FT OF SCHOOL? ES NO COMPENSATION INSURANCE ADDRESS (This section need not be completed if the permit is for one hundred ������� DISTRICT GROUP TYPE CONST.' FIRE ZONEPROCESSED BY dollars($100)or less.) CI ZIP I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to ARC ITECT OR ENGINEER TEL. become subject to the Workers'Compensation Laws. Q T'e�� g;e STATISTICAL CLASSIFICATION APT CONDO Date Applicant o ADDRESS �ftG D�j�/ CLASS NO.O9e DWELL UNITS NOTICE TO APPLICANT: If, after makin this Certificate of 3 /� �� lee. 9 REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONT TOR TEL.NO. 1 1 SETBACK YARD HWY PROP LINE WIDTH I Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS , LIC.NO. P L 20 1 � d SIDE >.. LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS P IL '= pa I hereby affirm that I am licensed under provisions of Chapter 9 rC C. SEWER MAP " ' t _i•1 2 C.3 SQ.FT.SIZE NO.OF ORES NO.O]AMILIES = (commencing with Section 7000)of Division 3 of the Business andr_i:: _ Professions Code,and my license is in full force and effect. NEW BK PG _ _R•`I a±_=OF—' License Number Lic.Class DESCRIPTION OF WORK /� ADD ❑ VALUATION � A I15,01-15E,; C 7 Ci oA (� 1-= W Contractor Date ALTER ❑ �/ 3' `"/ i '�} —yy REPAIR ❑ ❑ I am exempt under Sec. $ B.&P.C.for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ / 6 --_ Signature AP. LICANT(PRINT) TEL.NO. I LDMA Perm# Zi 13 I;_I-;;- I fs3e� '�j;'y ❑ I, as owner of the property, or my employees with wages as — /111W C I ) I t Icy 3 z�° their sole compensation,will do the work and the structure is ADDRESS Gd4w i not intended or offered for sale (Section 7044, Business and. FINAL DATE QY' s1Ls(��+t ° rofessions Code.) �] -• a ,�{,P WILLTHE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL 6� `�� ✓ j % •.: i ,To S} KJ I, as owner of theproperty, am exclusive) contracting withOR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BYmoi±"'i licensed contractors to construct the project.(Section 7044, YES❑ NO H I4!,e3C ❑ Business and-Professions Code.) I WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST ^ !JI(I U— Uri:i 16 Vj 1 FOR GUIDELINES. /� [,'•1" '^ 1"-) E, '`s+ 0 I hereby affirm that there is a construction lending agency for YES❑ NO❑ / ' D %`=`�'� the performance of the work for which this permit is issued(Sec. d, �' ' 8- 3097,Civ.C. . I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD �. 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' 1 certify that 1 have read this application and state that the above information is correct. I agree to comply With all county P.C.FEE. ✓,, © PERMIT FEE ordinances and State laws relating to building construction,and a. hereby authorize representatives of this County to enter upon ISSUANCE FEE the ove- entioned property for inspection purposes. '13 — INVESTIGATION m FEE TOTAL FEE /,I( >06r m, AMIC nt w AQ Dem i SEE REVERSE FOR EXPLANATORY LANGUAGE• / _f