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Home My Public Portal About6245 GOLDEN WEST AVE_Building__ ,-WORKERS' COMPENSATION DECLARATION iHerebynsure,oraa certif cane of Worke srlCompensat oificate of n eInsura 1f APPLICATION FOR BUILDING PERMIT or a'certified copy thereof (Sec. 3809, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NAIJ 1b company�tr �/ Nk BUILDING Certified copy is hereby furnished. . FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with 1 eco ty bu'Idin insp.c- BUILD IN ti}�,�I I ,_G„�/, ,IW : • tion department. ADDRES n- .IpV�" W��1 F vt ' ( .�u. i CITY" � I v`�) ZIP LOCALITY Date Applicant 4 t NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMP OM W RKERS' SIZE OF LOT' i �7�1 �'y NOW ON LOT 7 CROSS ST. 4 COMPENSATION INSURANCE ASSESSOR pt / (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK �p,J� PAGE �ta/ PARCEL el hundred dollars ($100) or less.) TEL./..r� !�� OWNER G-� NO.l6. .Y7�d USE ZONE OP hF I certify that in the performance of the work for which this /�y permit is issued, I shall not employ any person in any manner ADDRESS9j j �� KA '` - CONDITIONS so as to become subject to the Workers' Compensation Laws. Q CITY4A"N C`7mqur—( zip �1-7-A v Date Applicant ARCHITECT O J� TEL./p 1 Aa l 0 NOTICE TO APPLICANT: If,,after making. this Certificate of �VrENGINEER t- GJ��1 NOCa /�o0''Zl� DISTRICT GROU TYPE FIRE OCESSED BY Q Exemption, you should become subject to the Workers' j ( CONST. 'f Z E w Compensation provisions of the Labor Code, you must forth- ADDRESS�Z(U �` 7&J CrAW-C I)I 1'"2, with comply with such provisions or this permit shall be , i d � NO /} L /(fib STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR L�.tJ�(-> 1(-r / t5 S �4;6 a _ LICENSED CONTRACTORS DECLARATION \ LIC. CLASS NO. 0 DWELL. UNITS / I hereby affirm that I am licensed under provisions of Chapter 9 ` ADDRESS ! _ l(�t /• �0 / NO. (commencing with Section.7000)of Division 3 of the Business LIC.CITY /� wrICLASS p] /� SEWER MAP �j/rl"S�' C and Professions Code,and my license is in full fort nd effect. � BK. PG. VALIDATION Q i SQ. FT. NO. OF NO. OF CHECK License Number U � ! Lic, Class SIZE �G STORIES IFAMILIES ONE j� `f/ / ( VALUATION ContractoMl_,L�fJm-l 0•!Ow .Date Z DESCRIPTION OF WORK Q,U I- NEW $ ADD ❑ CJf�i GOQ. ❑1 am exempt under Sec. ► _Nr,r, ALTER E B_&P:C. for this reason REPAIR ❑ a ; sY ,:_: ;;•: Date: USE OF EXISTING BLDG. DEMO' ❑ Signature APPLICANT TEL((1 /L v g (PRINT) �`'�'_% NO.I lS FINAL OWNER-BUILDER DECLARATION. ! DATE I hereby affirm that I am exempt from the Contractor's Licensee,UUUll gDDRESS ,V�I 7 Law for the followingreason Section 7031.5, Business and �� 7 �( FINAL / $` ) �; Professions Code): PRESENT' ; By 2,.t; i,.1LLc rr3-� 77' ❑ I, as owner of the property, or m employees with BUILDING !Ick aFn"it P P Y• Y' ADDRESS �, � �,� wages as their sole compensation;will do the work and �' (� ,r,,07 i46,.1: the structure is not intended-or offered for sale(Section LOCALITY MOVING TEL. 7044, Business and Professions Code.) CONTRACTOR NO. ❑ I, as owner of The property, am exclusively contracting with licensed contractors to construct the project (Sec- Yh > '�"' ADDRESS tion 7044, Business and Professions Code.) . L,HECK 1464.56 REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION_LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH rv, { I hereby affirm that there is.a construction lending agency for RONT i: AVE the performance of the work for-which this permit is issued P.L.' (Sec. 3097, Civ. C.). SIDE { } j 01111130 Lender's Name, P.C. Fee$ / LDMA Ref. # 15 t!a •t Lender's Address � �0 Permit Fee 0 1 certify that I have read this application and state that the Issuance Fee � 7J LDMA P/C# 8 obo7ance ation is correct. I agree to comply with all County Investigation Fee + i ordind State lavys relating to building construction, Total Fee r Go LDMA Perm. # anduthoriz rresentatives of this County to enterupoa-me ti ned property for-inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE S' e o Applicant or Agent Date _ _ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN UILDING ADDRE o I hereby affirm that I have a certificate of consent to self insure, LDING A S 0^ W or a certificate of Workers' Compensation Insurance,or a certified 6 copy ther e 3800, C.) C ZIP LOCALITY Policy No. Company SIZEpF L T- /'e NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. 1bb O r 00,r NEAREST CROSS ST ❑ Certified copy is filed with the ounty uilding inspection TRACT BLOCK LOT NO. departmen. USE ZONE MAP NO. �i� Dat pyo Applicant ASSESSOR A �9K PAGE PARCEL Ate" .�j �� I j/ _ SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' WNE V C� TEL NO. YES NO COMPENSATION INSURANCE V WITHIN 1000 FT.OF SCHOOL? ADDRE (This section need not be completed if the permit is for one hundredfqetL �, r DISTRICT GROUP TYP CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) \ f I certify that in the performance of the work for which this permit �� I 7 is issued, I shall not employ any person in any manner so as to _ ZIP G / be me SUN t to the WorkersAorJ1p cation Laws. ARCHITECT OR ENGINEER � TEL NO. ,�1 (/"� STATISTICAL CLASSIFICATION APT CONDO Dat \ 1, _ Applicant C ADDRESS CLASS NO. DWELL UNITS NOTICETO APPLICANT If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRA ORTEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith (ol ,✓I ( =`�' _. I �� FRONT comply with such provisions or this permit shall be deemed revoked. DDRE D C.N q3 I P L LICENSED CONTRACTORS DECLARATION ( SIDE Y P L I hereby affirm that I am licensed underprovisions of Chapter 9 P,fZ` SEWER MAP (commencing with Section 7000)of Division 3 of the Business and F SIZE NO.OF STORIES NO.OF FAMILIES .Professions Code an y 'cense is in full force d efrfLct. NEW BK PG � License er 3 Lic.Cla S 1 V DESCRIPTION OF WORK ADD ❑ VALUATION , Q Contracto IIA L x1.14 �tQ Date r ALTER ❑ cc r - REPAIR ❑ El am exempt under Sec. $ O BAP.C.for this reason DEMOL ❑ LDMA P/C# W Date: USE OF EXISTINCALDG. - URM ❑ Signature �� APPLICANT(PRINT) TEL N0. LDMA Perm# - ANT. Z ❑ I, as owner of the property, or my employees with wages as Z rid%t o a their sole compensation, will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and � � FINAL DATE 330-7 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL / C OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ITEMS, L ^��- , Q I El 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY J licensed contractors to construct the project (Section 7044, YES❑ NO❑ i I s ITAL 117 ®70 Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING t:..i :�r� j'I =f'�I OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH y/�� ,J{' s CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR /' ;S 3 C t GUIDELINES. / -CHANGE _oil I hereby affirm that there is a construction lending agency for YES❑ No❑ %—y� a 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, i��'yy i �i.f i ij TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS COCKADE-., Ail l5/9% Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. _ 0 Lender's Address ` O OWNER OR AGENT o I certify that I have read this application and state under penalty 11iC�(- GJY 0 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE o with all county ordinances and State laws relating to building < construction, and hereby authorize representatives of this County ISSUANCE FEE to enter upon the above-mentioned property for inspection purposes. a INVESTIGATION FEE TOTAL FEE r Signature of Applicant or Agenl Oate SEE REVERSE FOR EXPLANATORY LANGUAGE