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Home My Public Portal About6143 GOLDEN WEST AVE_Building__ WORKERS'COMPENSATION DECLARATION f hereby affirm that 1 have certificate of consent to self APPLICATION FOR BUILDING PERMIT `,lull 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�, + _Company BUILD ING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDINGs� tion department. ADDRESS o lC Date Applicant CITY LCA ZIP '// Zqo LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT 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— I certify that in the performance of the work for which this OWNER f� ��/�U�� USE ZONE O. permit is issued, I shall not employ any person in any manner L s SPECIAL 8f, so as to be om subject to the Workers'Compensation Laws. ADDRESS -y CONDITIONS 0 f�� CITY a�G ZIP /�� V Date Applicant lkzlg 9gum NOTIC T APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICTGROUP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' ENGINEER NO..,/ CONST. ZONU Compensation provisions of the Labor Code, you must forth- ADDRESS �� r 0. W. with comply with such provisions or this permit shall be TEL deemed revoked. CONTRACTOR NO. STATISTICAL CLASS FIC TION APT. CONDO. Cn LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. QJ 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 VALIDATION SQ. FT. NO.OF NO.,OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE ❑ VALUATION DESCRIPTION OF WORK NEW $ Contractor Date ❑ � ADD ❑ 1 am exempt under Sec. [E]ALTER B.BP.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL F120 3 6 6'A EXISTING BLDG. Signature APPLICANT TEL. FINAL # 0 0 0 o a OWNER-BUILDER DECLARATION (PRINT) NO. DATE I hereby affirm that I am exempt from the Contractor's License J ° 1717 5 Law for the following reason (Section 7031.5, Business and ADDRESS FINAL 0 _ Professions Code): PRESENTBy ,0 7 �,7 5 v BUILDING j7t I, as owner of the property, or my employees with ADDRESS l� wages as their sole compensation,will do the work and 0 a 0 Jam:`$8 the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED YARD HWY TOTAL SETBACK Pl CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name LDMA Ref. # Lender's Address P.C. Fee$ Permit Fee CC I certify that I have read this application and state that the Issuance Fee 0cJ (O LDMA P/C# g above information is correct. I agree to comply with all County Investigation Fee q ordinances and State laws relating to building construction, Total Fee 0 5 LDMA Perm. q $ and hereby authorize representatives of this County to enter u o the obov entioned prop rty for inspection purp ses. `o SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ) APPLICATION FOR BUILDING PERMIT 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, BUILDING ADDRESS 6143 N. GOLDEN WEST ' or a certificate of Workers' Compensation Insurance,or a certified copy thereof(Sec.3500, Lab.C.) CITY ZIP 1046140 STATE FUND TEMPLE CITY 91780 LOCALITY Policy No. Company SIZE OF LCT NO.OF BLOGS.NOW ON LOT ❑ Certified Copy is hereby furnished. NEAREST CROSS ST DMertified copy is filed with the County building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. Date 11-1-9 Applicant RANDOL ROOFING ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO, _ COMPENSATION INSURANCE IKE FUROMOTO 285-4078 WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS dollars($100) or less.) .6143 N. GOLDEN WEST DISTRICT GROUP TY CONST. FIRE ZONE PROCESSED BY I certify that in the performance of the work for which this permit CITY ZIP TEMPLE CITY. CA 91780 / 3 is issued, I shall not employ any person in any manner'so as to become subject to the Workers' Compensation Laws. ARCHITECT OR ENGINEER TEL NO. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO.,=V DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subjectto the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith RANDOL ROOFING 288-4040 FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION 529. E. VALLEY BLVD. 451937 SIDE CITY LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 RAN fIABRTFJ., CA C—' 9SEWER MAP } (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO. F,STORIES NO.OF FAMILIES d Professions Code,and my license is in full force and effect. I I NEW. BK PG , 0 License Number 451937 LiC.Class C-39 DESCRIPTION OF WORK ADD 1:1 VALUATION V Contractor RANDOL ROOFINCMate 1-31-94 REROOF REAR TILE SECTION ON ALTER ❑ $ 2,000.00 2ND STORY WITH- 2 PLY .HOT BUILD REPAIR El0 El am exempt under Sec. $ BAP.C.for this reason UP. ROOFING SYSTEM. REINSTALL DEMOL ❑ LDMA P/c# W Date: USE OF EXISTING BLDG. URM ❑ N TILE. SFD 4 S S. Z Signature - APPLICANT(PRINT) TEL NO. LDMA Perm# "'''•T El 1, ROOFING 288-4040 ZI, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and 529 E VALLEY BLVD. SAN GABRIEL FINAL DATE a Professions Code.) _� WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J El7 '�' 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY I Ci i i L ^--��'�'� S0 licensed contractors to construct the project (Section 7044, -, Business and Professions Code.) YES❑ No❑ WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING i-li"s OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH j";j..( f� ` x!_±: 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 VES❑ NO❑ a the performance of the work for which this permit is issued(Sec. rnI HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 1_fif�•". _:_� Li3.3'J:` - 3097, Civ.C.) CHECKLIST.I UNDERSTAND MV REOUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 2.20 SECTIONS 2.20,100 THROUGH 2.20.140 CONCERNING HAZARDOUS 4 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD 0 Lender's Address 0 OWNER OR AGENT o I certify that I have read this application and state under penalty of perjury that the above information is correct.I agree to comply P.C.FEE - PERMIT FEE 78.90 o with all county ordinan es and State laws relating to building 00 construction and re authoriz re sentatives of is Co ty ISSUANCE FEE 26.40 ID to enter thea m 'one pr rty forinsy rp es. < / INVESTIGATION FEE TOTAL FEE 105.30 GgnaWre of Ap and Oa SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION insure,,, or affcertif carte of Workers'1Co=pte of c'Oinnt to mpensationSeInsuran e, A P P L I CATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING �' 3 4 • �' ��n �'T ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- ADDRESS (�3 �..4•/�p��.D T tion department. / CITY—rer PL& cl ZIP -11/t-760 LOCALITY Date Applicant ��7 NO. OF BLDGS. f NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 7r;//K 7Ha NOW ON LOT 11, CROSS ST. �. COMPENSATION INSURANCE ASSESSOR C O (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK J 3 PAGE 0 7-0 PARCELO hundred dollars ($100)or less.) 1. �� NL ,Q USE ZONE MAP �} a OWNER y K! NO. J 1 certify.that in the performance of the work for which this t Q •1 permit is issued, I shall not employ any person in any manner ADDRESS <� A POV� /� p SPECIAL > CONDITIONS so as to become subject to the Workers' Compensation Laws. O CITY ZIP U Date Applicant ARCHITECT OR TEL: NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER _NO. DISTRICT GROUP TYPE FIRE PRO ED BY - CONST ZONE Exemption, you should become subject to the Workers' L U LU Compensation provisions of the Labor Code, you must forth- ADDRESS Z. Mt �� "9*4� n. with comply with such provisions or this STATISTICAL CLASSIFICATION APT. CO DO.IVL to p y p permit shall be TEL. Z deemed revoked. ,. CONTRACTOR - NO. CLASS NO. DWELL. UNITS LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS (commencing with.Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY' CLASS BK. �i PG. VALIDATION SQ. FT NO. OF NO. OF CHECK License Number Lic. Class SIZE 3- STORIES I FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW I❑ 5 �� (�� ADD,. LLY �ji7v ► ❑I am exempt under Sec. - ' � ` r % FALTER} ❑ i, ; 6.8P.C. for this reason REPAIR ❑ Date: USE OF EXISTING BLDG. �ir'J�1C.F� DEMOL ❑ Signature APPLICANT' TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE 1 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 BUILDING❑ 1, as owner of the property, or my employees with t� I ADDRESS � ". i :�`� ;= ... trhi;-a ''F •:••T-��, wages as their sole compensation,will do the work and n L , M^i i-•^ >ti�• *�. J the structure is not intended or offered for sale(Section LQCAg3Y- +, + r , yti� 7044, Business and Professions Code.) MdqAG0410 r-TEL:- J } ?'"n+• `" �j 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.) --- c- REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH " 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. $ d / f ) LDMA Ref. # P.C. Fee Permit Fee �Q Lender's Address _ 0 1 certify that I have read this application and state that the Issuance Fee 7 s LDMA P/C# 8 above information is correct. I agree to comply with all County Investigation Fee C1(,tr.tT =1` ? , R ordinances and State laws relating to building construction, Total Fee �' LDMA Perm. # - •• a and hereby authorize resentatives of this County to enter "-,•r •7 upo ih bove-m d property for inspection purp ses. - `r J. '12- SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dat