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Home My Public Portal About6243 GOLDEN WEST AVE_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN UILDING ADDPE �Q Aw I hereby affirm that I have a certificate of consent to self insure, UILDING ADDR S YY�YYl��I(t/_�^ or a certificate of Workers' Compensation Insurance,or a certiI i ZIP copy thereof (Sec.3800, Lab.C.) e'y LOCALITY „r/ fE F 1\ Policy No. Company� SIZE F L T NO.OF BLDGS.NOW ON LOT ElCertified copy is hereby furnished. , Ob I� NEAREST CROSS.ST. ❑ Certified copy is filed with thepiunty building inspection TRACT BLOCK LOT NO. d artment USE ZONE MAP NO. '" ASSESSOR MAP BOOK PAGE PARCEL / 44 Date Applicant � O� Off/ 16 SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNI H N&7 TEL NO. YES No COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? (This section need not be completed if the permit is for one hundred ADDRESS dollars ($100) or less.) DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY I certify that in the performance of the work for which this permit Y ZI � , _ is issued, 1 shall not employ any person in any manner so as to ' O .7 lav 4RHITECTT OR ENGINEER TEL NO. become subje t t0 the WOrker�oompe ation Laws. STATISTICAL CLASSIFICATION APT CONDO I Dat Applicant/`Z ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject t0 the Workers' rADDRES ORS L NO.\\ SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith LW-M, `� T�• ' d i" ( FRONT comply with such provisions or this permit shall be deemed revoked. N P L LICENSED CONTRACTORS DECLARATION SIDE CL A PL I hereby affirm that I am licensed underprovisions of Chapter 9 �I � �I ( SEWER MAP (commencing with Section 7000)of Division 3 of the Business and Q.FT.SIZE NO,OF STORIES NO.OF FAMILIES Professions Code, d py lipyjSe is in full force and offpcctt. NEW C BK PG a License NU er Lic.Class —�V DESCRIPTION OF WORKADD 11❑] VALUATION , Q O tJ Contract ALV ►� Date 9�/ �� .� ALTER ❑ $ '�' �o U oo ❑ I am exempt under Sec. REPAIR 11 $ B.AP.C.for this reason DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. URM ❑ a' Signature 3('� 11j7.9 i Z APPLICANT(PRINT) TEL NO. LDMA Perm# +J•.57 `t Z ❑ I, as owner oft property, or my employees with wages as Zi ITEMS t.t iL their sole compensation, will do the work and the structure is ADDRESS O not intended or offered for sale (Section 7044, Business and FINAL DATE C TOTAL { � Professions Code.) - - WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL / � r ❑ 1, as owner of the y, Y g OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ` �` J CHECK 117.90 property, am exclusive) contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project (Section 7044, Business and Professions Code.) ves El No 111= CHANGE .00 WILL THE INTENDED USE OF THE BUIDLING 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 FOR _ U GIDELINES. 131300-0001 C•14 1 I hereby affirm that there is a construction lending agency for / _f r YES❑ No❑ /I/ ... _......... �7y �p{��1 w the performance of the Work for which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING -227 i --i``1 21 G' 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 p OWNER OR AGENT <.J o I certify that I have read this application and state under penalty 0 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 /0• < construction, and hereby authorize representatives of this County ISSUANCE FEE00 _ J to enter upon the above-mentioned property for inspection purposes. INVESTIGATION FEE TOTAL FEE � C! sigmt,,,e of Applkanf or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE c `PORKERS' COMPENSATION DECLARATION V to self nsure or a°certrtif carte of Works s'tComtpensat on of coent Insurance, �3'�+H P�`i C ►TION FOR BUILDING PERMIT or'a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy�No0 111 Company ��' 1.011 EICertified copy is hereby furnished. FOR BUILDING APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed wit e untyuildinginspec- BUILDING/_ tion department. ADDRESS 2j fi Date L �6 t/Pti+ (4�CJ ' r'i b- Yom.Applicant CITY'��M QI' �Y ZIP LOCALITY c-� D 5 T NO. OF BL G NEAREST CERTIFICATE OF EXE OM.WORKERS' SIZE OF LOT ,� 1 S ( NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed'if the permit is for one TRACT BLOCK LOT NO. MAP BOOK a.3 PAGE PARCEL ell hundred dollars ($100) or less.). �J� TEL. /{ USE ZONE MAP OWNER 'C Yj l/�DNLI NO. 4�d� S71 I certify that in the performance of the work for which thisSPECIAL 1 ') permit is issued, I shall not employ any person in any manner ADDRESS-311 `6 1]�JI, t/t f�A/�i V% �I O // X t7� CONDITIONS CL 0 so as to become subject to the Workers'Compensation Laws. CITY S � eV ZIP qf b O Date Applicant \ ARCHITECT OR ` TEL�a) yf1(j )L+/ DISTRI r G P TYPE F E PRO ESSED BY Q NOTICE TO APPLICANT: If, after ,making this Certificate of ENGINEER _('jG _ � o� NO. Oar D h �{ CONST. ZO l'- Exemption, you should become subject to the Workers' ADDRESS I Q c�� qq�� )) W Compensation provisions of the Labor Code, you must forth- \ / � G t rc a with comply with such provisions or this permit shall be � ll..``� 11// TEL r STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR GcrI�I�T1 (•r �/JL NO. ) Z LICENSED CONTRACTORS DECLARATION LIC. // CLASS DWELL. UNITS I hereby affirm that I am licensed.under provisions of Chapter 9 ADDRESS3' 1 .�. k.G / o. I O� NO.4I� y _ / ny'�].� LIC. SEWER MAP (commencing with Section 7000)of Division 3 of the Business CITY C�/�J'L'(�i�� &4- CLASS and Professions Code,and my license is in full fort nd effect. BK PG -VALIDATION SQ'. FT._ NO. OF NO. OF CHECK License Number 7 � Lic. Class SIZE STORIES !1 FAMILIES ONE „. .. . _„• „_ . �,{ VALUATION Contractor l 'C' t"� l}'C pais DESCRIPTION OF WORK 1 j ;l)71 NEW $ '7�J Dom,sf Pj ElI am exempt under Sec. ADD ❑ cif CJ7/• Poo.❑ B.&P.C. for this reasontI!st_t, REPAIR ;❑ $ USE OF Date: EXISTING BLDG. DEMO[ ❑ 5LL) `` f'1 t`t-�6 Signature APPLICANT �^ TEL. //,,,. y i, I rd g (PRINT) Y NO y'�I 4 FINAL �It_ OWNER-BUILDER.DECLARATION /�J��O DATE ` I hereby affirm That I am exempt from the Contractor's License ADDRESS �- v�tl'v 7 ` �(�•, ��r. �yy FINAL T f 4v c Law for the following reason (Section 7031.5, Business and u , ': Professions Code): Al PRESENT By f' �� Y�j f GI-'E1 �=' -t BUILDING ❑ I, as owner of the property, or my employeeswith ADDRESS D L•i`3�is'�� fi.• wages as their sole compensation;will do the work and a the structure is not intended or offered for'sale(Section NL CALITY i. i 7044, Business and Professions Code.) MOVING TEL. 1 ( ( 3�{ -,Etl i yf 1W• i _ CONTRACTOR NO, i 1 f:• •_t +t f .` ❑ I, as owner of the property,•am exclusively contracting with licensed contractors.to construct.the project (Sec- ` 151 I AM +p Qy,_; tion 7044,.Business and Professions Code.) ADDRESS REQUIRED TOTAL SETBACK FROM EXIST. v CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT S the performance of the work for which this permit,is issued P.L. (Sec. 3097, Civ. C.). SIDE. P.L. Lender's Name. .ry h ^ ? t m” P.C. Fee$ ,7g (� Permit Fee LDMA Ref. # 3 Lender's Address' oI c t I have read this application and state that the Issuance Fee '�1 ' LDMA P/C# S a I ve info motion is correct. I agree to comply with all County Investigation Fee R or mance and State��ws relating to building construction, Total Fee /}/gyp !v LDMA Perm. # < an her �y put ori{e'representatives of this County to enter up n Ike abov -mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ; _ Slgnatur of Applicant or Agent Date