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Home My Public Portal About6114 GOLDEN WEST AVE_Building__ WORKERS'COMPENSATION DECLARATION J'• :R I•he ''mosf ensation Insurance, affirm that I have a certificate of consent to Self - A P P L I CA_T I O N FOR BUILDING PERM' IT insure„ r d certificate of Workers' Comp 7 or•a certified copy thereof (Sec. 3800, Lab. C.) - COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. - Company BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS (J Certified copy is filed with the county building iitspec- BUILDING )q IZ S tion department. ADDRESS I �( C� s _. .. Date Applicant CITY• -�,f Q zip v LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' ' SIZE OF LO7 �D t/� 4O r NOW ON LOT p2 F BLDGS: NEAREST - - COMPENSATION INSURANCE CROSS ST. (This section”need not be completed if the'permit is for one. - - ASSESSOR -hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL.n vC USE ZONE MAP 1 certify that in the performance of the work for which-this OWNER �S NO / SPE y, permit is issued, I shall not employ any person in any manner SP AL - - so.as to b co a subject To the Work s'Corripe s n Daws. ADDRESS CONDITIONS _ qq 0 CITY ZIP_ Date L Applica NOTICE O APPLICANT: If, after making t rs Certificate of ARCHITECT OR TEL. i DISTRICT ROUP TYPE FIRE �ESSED_BY _ ENGINEER NO. _ CONST. ZONE Exemption, you should become subject' to the Workers' c/ r / U Compensation provisions of-the Labor Code, you must forth- ADDRESS with comply-with such provisions or this permit shall be" deemed revoked. TEL./`/'! STATISTICAL CLASSIFICATION APT. NDO. CONTRACTOR NO."` (fl LICENSED CONTRACTORS DECLARATION -LIG. CLASS NO. DWELL. UNITS hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC.-•- Professions Code, and my license is in full force'and effect. CITY CLASS BK. 77 VALIDATION SQ. FT. NO..OF. ( NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION WORK �bb�IV�J Ao 0 $ /1 ElI am-exempt under Sec. - (/ ' -w), ' ALTER -. 1 _: B.&P.C. for this reason S �' c 70 " REPAIR a Date: USE OF EXISTING BLDG. Si nature APPLICANT TEL. FINAL 9 �l OWNER-BUILDER DECLARATION PRINT NO. DATE I hereby affirm that I am exempt from the Contractor's License J9_ 50 9 A Law for the following reason (Section 7031.5, Business and ADDRESS FIN Professions Code): PRESENT By ' # 0 0 0 a 0 1 BUILDING I, as owner of the property, or my employees with ADDRESS• _- - o o59.25 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. t o•o.0 5 9.2-5 5 I, as owner of the property, am exclusively contracting CONTRACTOR NO. 7 21-86 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED YARD HWY' TOTAL SETBACK FROM IST. CONSTRUCTION LENDING AGENCY - SET BACK 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 P.L. Q Lender's Name LDMA Ref. # m - - - P.C. Fee$-- '- -' Permit Fee i - Lender's Address _ j I certify that t have read.this application and state that the _. .--- Issuance Fee V LDMA-P/C# ' t above information is correct. I agree to comply with all County Investigation Fee m ordinances and State laws relating to building.construction, . I.- _. .._ Total Fee J LDMA Perm. # u and hereby authorize representatives of this County to enter upon h above-menton d property for inspection purposes. aAL SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o pplicant or Agent Date - ••" - - - - - - - - "" - - " - WORKERS' COMPENSATION DECLARATION sureaffirm that I havecertificate of consent to self APPLICATION P P L I CAT I® FORBUILDING PERMIT insure,, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Compony I E Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Lr G 1 W Certified copy is filed with the county building inspec- BUILDING 1 tion department. ADDRESS 0114 , ) Dote. Applicant CITY ZIP LOCALITY - CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. r NEAREST i COMPENSATION-INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be co'rnpleted if the permit is for one ASSESSOR' hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. - USE Z NE MAP ' certify that in the performance of the work for which this OWNER ANO. SPE Irmit is issued, I shall not employ any person in any manner + 1 SPECIAL , 'as to become subject to the Work s'Com ensation Laws. ADDRESS (SVC,Id )17�� CONDITIONS U Applicant L" l� CITY ZIP 'E TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. ry DISTRICT GR UP TYPE FIRE PROCESSED BY 0 ENGINEER NO. C U tion, you should become subject to the Workers' ��) ,- CONS(T,� ZO ensation provisions of the Labor Code, you must forth- ADDRESS JGV 1 )mply with such provisions or this permit shall be ;2) Ll. ! revoked. TEL. STATISTICAL CLASSIFICATION APT. CO DO. U)CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION LIC._ CLASS NO. 7, 1 DWELL. UNITS affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP acing with Section 7000)of Division 3 of the Business and LIC. .',ins Code, and my license is in full force and effect. CITY CLASS BK � VALIDATION SQ. FT. NO. OF NO.OF CHECK > PG -77 ,e Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION DESCRIPTION OF WORK W ❑ Tractor Date ADD ❑ $ 1 I am exempt under Sec. Pk-_- P) A ALTER ❑ B.BP.C. for this reason REPAIR $ Date: USE OI F BLDG. DEMO 1771 f Q 8 ? g Si nature APPLICANT PRINT ff�� //�� I TELNO.. FINAL OWNER-BUILDER DECLARATION DATE � 49 j"{`. o o;o 0 0'J 1-hereby affirm that-I am exempt from the.Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL j o o ]8 (j Q ON Professions Code): PRE BY ENT BUILDING o a o 7 8, In Q y IT7r,J\ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and Iy� the structure is not intended or offered for sale(Section LOCALITY f !� }� C 8 7044, Business and Professions Code). MOVING TEL. f i:K a O'O ` 1, as owner of the property, am exclusive) contractingCONTRACTOR NO. 1 -„ fir.,.� with licensed contractors to construct the project (Sec- ADDRESS t .) 01 tion 7044, Business and Professions Code). f' CONSTRUCTION LENDING AGENCY SETT BACKK YARD HWY ED TOTAPREOTPAINEFR 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 P.L. Lender's Name LDMA Ref. # Lender's Address P.C. Fee$ Permit Fee [t� I certify that I have read this application and state that the Issuance Fee 5 (1 LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee _ordinances and State laws relating to building construction, Total Fee LDMA'Perm.'# and hereby authorize representati.ves'of this County to enter u o the above-mention d roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date R APPLICATION FOR BUILDING PERMIT COUNTY 0F'L0S 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, BUILDING ADDRESS �e or a certificate of Workers' Compensation Insurance,or a certified All C;Lly ZIP V copy thereof(Sec.3800,Lab.C.) n LOCALITY Policy No. Company SIZE OF LOT v� NO.OF BLDGS.NOW ON LOTP, Q ❑ Certified Copy is hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK "LOT NO. USE ZONE MAP NO. department. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL�� _ -��gR�}} ,(�� ,€'/tvp SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' �` =N L� N SS� �(Z 6 OD 0 WITHIN 1000 FT.OF SCHOOL? Yes No COMPENSATION INSURANCE This section need not be completed if the permit is for one hundred ADDRESS /� ( P / DISTRICT GROUP TYPE CONST. FIRE ZONE PROC Y dollars ($100) or less.) IAl. Vf/ �f I certify that in the performance of the work for which this permit CI Z! '/ is issued, I shall not employ any person in any manner so as to RCHI CT OR ENGINES - TEL NO. become subject to the Workers'Compensation�Laws. STATISTICAL CLA�SSIF/DATION APT CONDO Date Z� Applican044A, � ADDRESS CLASS NO. s�� DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith — PObel�.D G_ —' FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATIONSIDE CITY LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9SEWER MAP (commencing with Section 7000)of Division 3 Of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW 11 El BK PG d RIPTION OF W VALUATION GLS License Number Lic.Class 4�• Poo. 0 �* t� ADD ❑ ,� (, Contractor Date 'T ALTER $ I�`"� --T.REPAIR ::❑ I^IL•t• s'9` ❑ I am exempt under Sec. $ 3 0 1V� ��f O A L \}` "��'� �C'L.� ��V� DEMOL '�.❑ LDMA P/C# .. ..._ J� .. � ._.. 2� W B.&P.C, for this reason �rt� Date: USE OF EXISTING BLDG. URM ❑. TOTAL T ! �'IG"�''�--g } a Signature AP 1 T /^ LDMA Perm# i O t AL 102 nn x 0 z ❑ I, as owner of the property, or my employees with wages as � �,.CHECK31.11 n 4 their sole compensation, will do the work and the structure is p/��p/q /�// not intended or offered for sale (Section 7044, Business and �/'` Al / O`oV ' `i FINAL DATE __: Q CHANGE .150 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 3 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J ❑ I, as owner of the property, am exclusive) contracting with a y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY � _ (I 'y�I licensed contractors to construct the project (Section 7044, VES 1:1 NO E] I}i f {S"{{ _'f �/ , Business and Professions Code.) -j ;9 WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDINGt -y per} OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 8416 Itit}10 :u CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ NO❑ N the performance Of the Work for which this permit Is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,CIV.C.) 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 HAZARDOUS 3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. o Lender's Address OWNER OR AGENT 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 with all county ordinances and State laws relating to building construction, and hereby authorize representatives of this County ISSUANCE FEE co to antern on the above-mentioned property for inspection pur oses. Z •W J a Qq - �. \`J INVESTIGATION FEE TOTAL FEE �'- SI,- m APorca OX SEE REVERSE FOR EXPLANATORY LANGUAGE - WORKERS' COMPENSATION DECLARATION-1 •11 hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers'Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Compony BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS LOCALITY NEAREST s Date Applicant CITY 94CIQLY ZIP e2 CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. .��77 ASSESSOR _ COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT Ota MAP BOOK I PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP �! TRACT hundred dollars ($100)or less.) BLOCK LOT NO. / NO. TEL. �" r/ SPECIAL y I certify Thaf'in the performance of the work for which this OWNER e 55>�NO S- CONDITIONS i3. permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY so as.to become subject to the Wompe t'on Laws. ADDRESS &Z' � CONST. ZONE u QP1E Date " Applican CITY Gl ZIP Ly/ v STATISTICAL CLASSIFICATION APT, ]CONDO. NOTIC TO APPLICANT: If, after making th Certificate of ARCHITECT OR TEL. ENGINEER NO. CLASS NO. DWELL. UNITS W Exemption, you should become subject to the Workers` t. Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP. H with comply with such provisions or this permit shall be Z TEL. VALIDATION deemed revoked. CONTRACTOR NO. BK. ' PG, LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter.9 ADDRESS NO. ALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. DO Professions Code, and my license is in full force and effect. CITY CLASS 6�� ► SQ. FT. NO.OF / NO. OF CHECK License Number tic.Class SIZE . STORIES { FAMILIES ONE i NEW $ Contractor Date DESCRIPTION OF WORK ADD ❑ 1 am exempt under Sec. ALTER E] FINAL .�� B.SP.C. for this reason I Agaa cx-,- REPAIR ❑ DATE _J v USE OF -�r DEMOL FINAL Date: EXISTING BLDG. ))-0W ❑ y Signature APPLICANT TEL. OWNER-BUILDER DECLARATION PRINT NO. I hereby affirm that I am exempt from the Contractor's License ADDRESS , o i n Law for the following reason (Section.7031.5, Business and Pro ssions Code): PRESENT o BUILDING t t I, as owner of The property, or my employees with ADDRESS -2C " �.� • 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). 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 m P.L. o Lender's Name Lender's Address P.C. Fee$ Permit Fee �� r [-certify that I have read this application and state:that the Issuance Fee .Sd above information is correct. I agree to comply with.all County Investigation Fee g ordinances and State laws relating to building construction, Total Fee 4 a d and hereby authorize representatives of this County to enter !O upon thel bove-mentione pr rtfor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of A lic nt or Agent Date WORKERS' COMPENSATION DECLARATION f� hereby affirm I have o certificate of consent to self APPLICATION FOR BUI - DING PERMIT insure, or a certificate of Workers' Compensation Insurance, - or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND AFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS F! Certified copy is filed with the county building inspec- BUILDING El / //� /' tion department. ADDRESS 6 Cl670 eW Date Applicant CITY G � ZIP l!'7 6ry O CALI Y v^ CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. EAREST COMPENSATION INSURANCE SIZE OF LOT Y�C�3O NOW ON LOT ROSS S (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. SSESSO hundred dollars ($100)or less.) P BO K E PARCEL TEL. � SE ZO P 1 certify that in the performance of a work for which this OWNER f GG NO�s3 'Z permit is issued, I shall not employ person i any manner �� SPECIAL d° so asJ�tobomesubject to the Wo a s'C tion Laws. ADDRESS CONDITIONS 0 �I CITY ZIP U Dote Applicant NOTICE TO APPLICANT: If, after making this Certificate of CT OR /�&�..,,��,,,�.� r TEL. 1 DISTRICT GROUP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' ENGINEE </ /�/I� / u O. 20 o L� CONST1.� ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS �1 !�`. S7. �1Q$ /i1 `-' �� V � W with comply with such provisions or this permit shall be TEL. y d deemed revoked. CONTRACTOR NO STATISTICAL CLASSIF! ATION APT. NDO. to z LICENSED CONTRACTORS DECLARATION CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and`effect. CITY CLASS BK VA VRa SO. FT OF NO. OF CHECK License Number Lic.Class SIZE O S IES FAMILIES ONE ° (' �V Contractor Date DESCRIP71 OF WORK 2 J r' NEW ❑ $ J/�VALUATION J�//� .°2 51.8 2 ❑ I am exempt under Sec. r o ADD ❑ V (/z ° .2 5 1.8 2 ALTER B.&P.C. for this reason IREPAIR ❑ $ 0 6 2.7'-i 8 8 Date: X TI F G BLDG. �1 C IL//� �(, DEMOL ❑ Signature AP LICANT / TEL. g OWNER-BUILDER DECLARATION I(PRINT) 01 / /LAMB, 0. 2Pl'�fP�JP" FINAL DATE I hereby affirm that I am exempt from the Contr ctor's License ADDRESS C a 9 �I C¢ � t �r Law for the following reason (Section 70 31.5, siness and FINAL Professions Code): PRESENT BY El BUILDING I, as owner of the property, or my employ s wit ADDRESS wages as their sole compensation,will do the war and the structure is not intended or offered for sale(Section LOCALITY \` 7044, Business and Professions Code). MOVING E . ❑ I, as owner of the property, am exclusively contracting CONTRACTOR with licensed contractors to construct the project (Sec- ADDRESS ` tion 7044, Business and Professions Code). \ CONSTRUCTION LENDING'AGENCY SETOBACKD YARD HWY T TA OPALINE CKF WID 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 P.L. I _ Lender's Name Qn m P.C. Fee$ 15- t U o'er Permit Fee LDMA Ref. # Lender's Address 3 g I certify that I have read this application and state that theIssuance Fee LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee 0 oidi nces and State laws relating to building construction, Total Fee LDMA Perm. # an ereby authorize representatives of this County to enter u o V- Ovw inspection purposes. 61.2SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Daie