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HomeMy Public PortalAbout5915-5927 OAK AVE_Building__ V(RKERS COMPENSATION DECLARATION lure bor a cr.ern Acte of W6rkersrtCo�mtpensat on Insu:an e'� APPLICATION FOR BUILDING P E RM I T or a certified copy thereof(Sec 380 Lab C) COUNTY'OF LOS ANGELES BUILDING AND SAFETY Policy No R'114691 Company pm abomirg 1:1 Certified copy is hereby furnished FOR APPLICANT TO FILL IN , 6 AADDRIE,SS �� OAA< ST ❑ Certified copy is filed with the county building mspecRFSNS FA N t7 5T _ , Oil"7 tion department :01 zip LOCALITYDate ro*Zq 'I Applicant CITY LE CATv� NO OF BLDGS NEAREST LA S CERTIFICATE OF EXEMPTIA4 FROM WORKERS SIZE OF LOT 1 t,r.6v S F NOW ON LOT 991 CROSS ST 1UNA& COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL hundred dollars ($100)or less) w A 1 N6- G NO OWNER �vs 1 USE ZONE IMP / J6 , I certify that m the performance of the work for which this M -- SPECIAL permit is issued I shall not employ any person in any manner ADDRESS s —6), ONDITIONS � so as to become subject to the Workers Compensation Laws CITY ZIP 7 u Date Applicant ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE P D BY Q NOTICE TO APPLICANT If after a mg this Certificate of ENGINEER 6 - O -l If CONST NE Exemption you should become subject to the Workers Q W Compensation provisions of the Labor Code you must forth ADDRESS 8 A` a in with comply with such provisions or this permit shall be CONTRACTOR TELNO STATISTICAL C ?!!!DWELL N APT ONDO Z deemed revoked z LICENSED CONTRACTORS DECLARATION LIC CLASS NO 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 LIC and Professions Code and my license is in full force and effect CITY CLASS BK PG VALIDATION SQ EI. NO OF NO OF ( CHECK License Number Lic Class SIZE / STORIES D ONE 23 VALUATION AC Contractor Date DESCRIPTION OF WORK S NEW ACGT■* El am exempt under Sec E ADD LJALTER E3No. 3307 IW3.E3 REPAIR El&P C for this reason $ , 1 ITEMS •+s7 USE °a1e EXISTING BLDG A �090A DEMO' ❑ �Tu4tT/�w. 15M.83Signature APPLICANT MI NG'M TEL FINAL 4r�yn i5 .vim NQ. 29.M—IMM OWNER BUILDER DECLARATION (PRINT) S DATE00 I hereby affirm that 1 am exempt from the Contractor s License ADDRESS � s Law for the following reason (Section 7031 5 Business and FINAL t Professions Code) PRESENT BY ❑ I as owner of the property or my employees with ADDRESS 1 5/16/89 wages as their sole compensation will do the work and LOCALITY , 3321 1 AM11 1$ the structure is not intended or offered for sale(Section 7044 Business and Professions Code) MOVING TEL ❑ I as owner of the property am exclusively contracting CONTRACTOR NO 1` with licensed contractors to construct the project (Sec ADDRESS 4LCI a tion 7044 Business and Professions Code) UIRED TOTAL SETBACK FROM EXIST -,-,r �0C 1 1 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE ID ��J� '' I hereby affirm that there is a construction lending agency for FRONT 4 1oo„Dp ' 1 the performance of the work for which this permit is issued P L 99 (Sec 3097 Civ C) SI 0 $^OSS S-O Spun.l i ITt�L 2091 Lender s Name / t HE, K 201 13 PC Fee$ /s Permit FeeOUP-9LDS Ref # Lender s Address ( c 1 certify that I have read this application and state that the • Issuance Fee ' I LDMA P/C# above information is correct I agree to comply with all County Investigaho ordinances and State laws relating to building construction Total Fe LDMA Perm # 0000-0001 6/29f'Il and hereby authorize representatives of this County to enter 191-Do 1 AM11 1_ upon the above mentioned property for inspection purposes oqx • I CP.2cl go SEE REVERSE FOR EXPLANATORY LANGUAGE Sibnoture of Applicant or Agent Date t ,APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN BUILDING ADDRESS WORKER S COMPENSATION DECLARATION BUILDING ESS I hereby affirm that 1 have a certificate of consent to set Insure Q or a certificate of Workers Compensation Insurance or a certified V� copy thereof Sec Leo C I C LP � �JeI1 J LOCALITY 7 I r C Poll y No b Company �A g OF LOT NO OF B NOW ON LOT (�(� 13 Certified copy Is hereby furnished NEAREST CROSS ST nt LK Cerbfled copy is filed with the my building inspection � BLOCK LOT NO USEZONE MAP NO EL nData � ,ApplKra ASS R4(i PARC/rY) l _ a SPECIAL CONDITIONS CERTIFICATE OF EXEMPTI OM WORKERS °WN TEL NO vv \,/ YES NO COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? r (This section need not be completed If the permit is for one hundred ADDR ST 1, S DISTRICT F,31 P TYPE CONST FIRE ZONE BY Ideate($1W)or lees) CI ZIP �'�� Tj' I candy that In the performance of the work for which this permit A�.. � .,\L/� 1 IB Issued I shall not employ any person In any manner so as to ARCHITECT OR ENGINEER TEL NO become subject to the Workers Compensation Laws STATISTICAL FICATION APT CONDO Date Applicant ADDRESS CLASS NO 4 DWELL UNITS NOTICE TO APPLICANT If after making this Certificate of REOUIRED TOTAL SETBACK FROM EXIST Exemption you should become subject to the Workers S r�/,e T TEL ��o SEr BAac YARD HWY PROP LINE WIDTH Compensation provisions d the labor Cade you must forthwith R / O FRONT comply with such provisions or this permit shall be deemed revoked AD O7-6 �Q/ PL LICENSED CONTRACTORS DECLARATION CITYLIC 3ci ff 7 SPIL IDE a I hereby affirm that I am licensed under provisions d Chapter 9 8119'a 21( SEWERMAP (commencing with Section 7000)of Division 3 d the Business and NO OF STORES NO DF UES Professions Code and my license Is in full force effect a* NEW ❑ BK L.� PG , ' ESCRIPTION OF WORK ADD ❑ VAWATKIN License Number Lc w Cle Contractor$1069 OW&A Date If—A gI ALTER ❑ $ z ❑ 1 am exempt under Sec REPAIR ❑ $ B&P C for this reason U6MIEM1— 61—A& DEMOL LOMA P/s Date USE OF tx18TINGs„t URM ❑ Signature APPLI ( IMS N TEL NO LOMA Famh N 1 ❑ I as owner of the property or my employees with wages as DAft 1A d ?` p ALCT T their sole compensation well do the work and the structure Is / F not intended or offered for sale(Section 7044 Business and97 T TO b �� OS 011 PTOfes810r18 Code) wILLTHEAPPUCMITORFUTUREBUILDINOOCCURMITNMIDLEANAZARDOUSMATEA4LL ❑ I es owner of the property am exclusively contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN 1 ITEMS P pertY N THE AMOUNTS RED ON THE HAZARDOUS MATERIALS INFORMATION OWDE1 FINAL licensed contractors to construct the project (Section 7044 VES❑ NOVITAL $.Q� Business and Professions Code) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING �+ ,�}� CONSTRUC770NLENDINOAGENCY °�'P"'E�'IREAPERMITFORCON6T WrMORM=FrAnONFAOMTHESOUTH CHECK F 00 COAST AIR QUALITY MANAGEMENT DISTRICT WAOMD)SEE PERMITTING CHECKLIST �,} �,�r ,J FOR GUIDELINES CHANGE °OLI I hereby affirm that there w e construction lending agency for YES❑ NOI the performance of the work for which this permit Is lowed(Sec I HAVE READ THE MAZAP40M MATERIALS INFORMATION GUIDE AND THE SCAOMD 3097 CIV C) PERMITTING CHECKLIST I WDER81AND MY REOUIRBAENTS UNDER THE LOS ANGELES Lenders Name couNTYQo saosEcnQNesao,00TwrouGHIS),4o NG OU-0001 5/ 3/9L' A PERMIT FROM THE SCAQYm Lenders Address CW,CRAS§ft Ali 9° 0 1 certify that I have read this application and state that the above PC FEE PERMIT FEE h Information is correct I agree to comply with all county manoea V ordState laws relating to building construction and ' hereby a a representatives of this County to enter upon ISSUANCE FEE ,3 DZ) property for inspection purposp INVESTIGATION FEE TOTAL FEE vA°I DAY 7 SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES t BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL ' IN BUILDING [ R� �p I hereby affirm that I have a certificate of consent to self Insure BUILDIN �E ` y' /�`�`'� or a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) CITY IF, LOCALR oil Policy No Company SIZE OF LOT NO OF IBLDGS NOW ON LOT Certified copy Is hereby furnished NEAREST CROSS ST LOCK LOT NO department USE ZONE MAP NO 1:1 Certified copy Is filed with the county building inspection TRACT B Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS OWNER % TEL NO COMPENSAl1ON INSURANCE tQ µ WITHIN 1000 FT OF SCHOOLS YEs No (This section need not be completed if the permit is for one hundred ADDR 7 dollars($100)Or less) O tJ /� Q DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY I certify that in the performance of the work for which this permit CITY ? r ZIPn� 911 �O O� is issued I shall not employ any person in arty manner so as to ARCH ECT OR ENGINEER TEL NO become subject to the Workers Compensation Laws STATISTICAL CL.ASS§.1CATION APT CONDO Date Applicant ADDRESS CLASS NO 151 120" DWELL UNITS NOTICE 70 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 complywith such provisions or this permit shall be deemed revoked FRONT P ADDRESS LIC NO P L LICENSED CONTRACTORS DECLARATION SIDE CITY LIC CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO FT SIZE NO OF STORIES NO OF FAMILIES Professions Code and my license is in full force and effect /� /� NEW ❑ BK PG ► d License Number Lrc Gass DESCRIPTION O RK Iii^ ADD ❑ VALUATION U Contractor Date ALTER IV ❑ 1 am exempt under Sec REPAIR ❑ $ B&PC for this reason DEMOL 13LDMA PTC# W Date RM ❑ n. Signature APPLICANT( TEL NO LDMA Perm# 23 Z ❑ 1 as owner of the property or my employees with wages as z AM 'T their sole compensation will do the work and the structure is ADDRESS F 715017, 9G CC, not intended or offered for sale (Section 7044 Business and FINAL DATF— �/ G f Professions Code) WALL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL KN!( ❑ 1 as owner of theOR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE property am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 8 AUTlicensed contractors to construct the project (Section 7044 YES❑ NO❑ e Business and Professions Code) ?��ryry7 WALL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING 3303 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR ITEMS 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 iHavEREIwTHEHnZARoousMnTERUoN LsiwFORMnnGwoEANOT}♦EscAQMOPERMrtriNG TI+IAL ^ m a � 3087 CIV C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE I'(+y.L 7C CY TITLE HC��/2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS iLenders Name MATERIALS REPORTING AND FOR OBDUNING A PERMIT FROM THE SCAQMD CHANGE 03 o Lenders Address fl 1iVG C OWNER OR AGENT F, I certify that I have read this application and state under penalty O of perjury that the above information is correct I agree to comply PC FEE PERMIT FEE N with all county ordinances and State laws relating to building • 1 d4_ G 11 C l f y � construction nd hereby authonze presentatives of this County ISSUANCE FEE /} m ter he above mention perty for inspection.7p�ur)pLDeeess 45 • m ESTIGATION FEE TOTAL FEE a SEE REVERSE FOR EXPLANATORY LA GUAGE t • APPLICATION FOR BUILDING PERMIT TY F ANGELES + BUILDING AND SAFETY r COON O LOS S ,d, WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN - ^ LDING ADDRE A I hereby affirm that I have a certificate of consent to self insure BUI a or a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) CITY / r _L C ZIP �T �,C! LOCALITY Policy No Company SIZE qF Lot NO OF SLOGS NOW ON LOT ❑ Certified copy Is hereby furnished I NEAREST CROSS ST ❑ Certified copy Is filed with the county building Inspection TRACT t BLOCK — LOT NO department USE ZONE MAP NO Date Applicant ASSESSOR MAP RA06A PARCEL SPECIAL CONDITIONS �,VA CERTIFICATE OF EXEMPTION FROM WORKERS TEL No COMPENSATION INSURANCE SaG� C Pw WITHIN 1000 FT OF SCHOOL? YES No (This section meed not be completed If the permit Is for one hundred ADD RESS - DISTRICT GROUP TYPE CONST FIRE ZONE PROCE dollars($100)or less) F I Certify that In the performance of the work for which this permit CITY-:Mcu /I C MP �08 + fdT is Issued I shall not employ any person in arty manner so as to �� OR ENGINEER TEL NO V CC become subject to the Workers Compensation laws STATISTICAL CLASSIFICATION APT CON Date Applicant ADDRESS CLASS NO DWELL UNITS NOTICE TO APPLICANT If after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption you should become subject to the Workers TEL NO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code you must forthwith FRONT ' comply with such provisions or this permit shall be deemed revoked ADDRE W ww LIC NO PL LICENSED CONTRACTORS DECLARATION SAL CITY LK:CLA83 PL I hereby affirm that I am licensed underprovisans of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO FT SIZE NO OF STORIES NO OF FAMILIES Professions Code and my license Is In full force aril effect NEW 13K PG , dw License Number Lac Class DESC I OF W107 Q� DO ADD �noN O Contractor Date d ALTER $(5%1*09 O (�� ❑ I am exempt under Sec a C u REPAIR [3 B&PC for this reason DEMOL ❑ LDMA P/C# W Date SE UF EXISTING URM ❑ f coCL Signature APPLICANT(PR94T) TEL NO LDMA Perm# 'TL Z ❑ 1 as owner of the property or my employees with wages as z At C T their sole compensation will do the work and the structure is ADDRESS 0 7,03- cry 90 not Intended or offered for sale (Section 7044 Business and FINAL DATE Q p Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OOCURANT HANDLE A HAZARDOUS MArERIAL S 25l?..s + I eS owner Of the property am exclusively COrltraCtlrtg With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE i IICesSed owner of this r construct the project (Section 7044it AMOUNTS SPECD ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY jL 9 AL 6T%®r Business and Professions Code) YES❑ NO,; WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING 3",03 240 30 OCCUPANTCONSTRUCTION LENDING AGENCY GUIDELINES.REQUIRE A PERMIT FOR CONSTRUCTION O) EE MRMITN FROM THE 80UTH FOR, F 3 � T rtMs COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)BEE PERMITTING CHECKLIST FOR I hereby affirm that there is a construction lending agency for YES❑ �❑ y' r' 'T�jTAL 2-90 $>d C4 the performance Of the work for which this permit IS i8�ued(Sec I WWE READ THE HAZAADOUSMATERILS INFORMATION GUIDE AND THESCAOMPERMnTNG r CID 3097 Civ C) CHECKLIST I UNDERSTAND MY REOUIREMENTS UNDER THE LOS ANGELES COUNrY CODE � E % 296 fir, W TmJ:2 CHAPTER 2 20 SECTIONS 2 20100 THROUGH 2 20140 CONCERNING HAZARDOUS Lenders Name MATERIALS REPORTING AND FOR OBWNNG A PERMIT FROM THE SCAQMD NAhIGE 00 Landers Address C WMER OR AGM c I certify that I have read this application and state under penalty /T C of perjury that the above Information Is correct I agree to comply PC FEE �D �� PERMIT FEE (- N with all County ordinances and State laws relating to budding 990-0001 V construction and hereby authorize representatives of this County ISSUANCE FEE )Z1:0 1 ASI $ 91 to e!ppon the above tared rb+for inspection ro . INVESTIGATION FEE TOTAL Fej SEE REVERSE FOR EXPLANATORY LANGUAGEgyO, 0 APPLICATION FOR BUILDING PERMIT 1. COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKERS COMPENSATION DECLARATION ti FOR APPLICANT TO FILL IN BUILDING ADDRESS L ^ O I hereby affirm that I have a certificate of consent to self insure BUILDING ADDRESS S or a certificate of Workers Compensation Insurance or a certified CITY 'eA 1q D LOCAIJTY ?- ' , copy thereof(Sec 3800 Lab C) L Policy NoCompany SIZE OF LOT NO OF BLDGS NOW O LOT ❑ Certified copy is hereby furnished NEAREST CROSS ST ❑ Certified copy Is filed with the county building Inspection TRACT BLOCK LAT NO LA S I department i t I USE ZONEMAP NO Date Applicant ASSESSOR MAP BOOK PAGE PARCEL` ! � SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS OWNER TEL NO YES NO j COMPENSATION INSURANCE (&A WITHIN 1000 FT OF SCHOOL? t (This section need not be completed if the permit i8 for one hundred ADDR S I DISTRICT GROUP TYPE ST FIRE ZONE PROCESSED BY 1 dollars($100)or less) CITY `r. ZIPr I certify that in the performance of the work for which this permit -IrwmL S I'� o Is Timed 1 shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO d ' become subject to the Workers Compensation Laws /� STATISTICAL CATION APT CONDO DateApplicant lt'h �G! S� iQ ADDRESS CLASS NO CDWELL UNITS NOTICE 70 APPLICANT If after making this Certificate oft , REQUIRED TOTAL SETBACK FROM EXIST Exemption you should become subject to the Wbrkere CONTRACTOR TEL NO SET BACK YARD HWY PROP LINE WIDTH ComptInsation provisions of the Labor Code you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked ADDRESS NO PL LICENSED CONTRACTORS DECLARATION S 2 SIDE I CITY uC CLASS P L -, I hereby affirm that I am licensed underprovisionls of Chapter 9 V SEWER MAP w (commencing with Section 7000)of Division 3 of the Business and 80 FT SIZE NO OF STORIES NO OF FAMILIES NEW BK PG t7CCT Professions Code my IOenss.ia m full force and effect Tr License Number Lic Class c-41DESCRI NOF WORK ADD ❑ 1dILUATION , "''r`t �(� Cj�I� ,.ti J.. (j Contractor I t.T�=Zr ALTER ❑ $ ��� f t ❑ 1 am exempt under Sec ` cc REPAIR ❑ $ At(T.-, 0 BSPC I this reason DEMOL ❑ LDW PIC f ��CIJ 137Al Date .� USE OF EXISTING BLDG URM ❑ i ITERS Signatu APPLICANT(PRINT) TEL NO LDMA Perm f Z ❑ 1 as owner of the property or my employees with wages as O TUTAL 157.60- their sole compensation will do the work and the structure Is ADDRESS 0FINAL DATE C HEC Y x,57 r to not intended or offered for sale (Section 7044 Business and s .2S-�S �00. CHANCE Jt1 Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL = r ❑ I 88 Owner Of file property am exclusively contracting Wlttl OR A MOITURE CONVUNNG A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE licensed o contractors r construct the project (Section 7044it AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATGN GUIDE? FINAL BY > 1 YES 13 No 13Business and Professions Code) N �y 1�y`� i WILL THE INTENDED USE OF THE BLAMING BY THE APPLICANT OR FUTURE BUILDING 0000 Ill 4/24,199 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR GUAM MANAGEMENT DISTRICT(WAOMD)SEE PERMING CHECKUST FOR 0089 f FM t�t 9 02 GUKUEUNE& I hereby affirm that there is a construction lending agency for YES 13 NoO ' CM the performance Of the work for which this permit is issued(Sec �READTHE HAZARDOUS MATERIALS INFOF&AATIONGUIDEAND THE SCAOMDPERMTTTING A r m 3097 CN C) CHECKLIST 1 UNDERSOWD MY REQUI EMENTs UNDER THE LOS ANGELES COUNTY CODE Of TrILE 2 CHAPTER 2 20 SECTIONS 2 20 700 THROUGH 2 20140 CONCERNING HAZARDOUS Lenders Name MATERIALS REPORTING AND FOR OHOINNG A PERMIT FROM THE SCAOMD _ o Lenders Address 0 owNM OR AOewr I certify that I have read this application and state under penalty , g of perjury that the above Information is correct I agree to comply PC FEE PERMITFEE with all county ordinances and State laws relating to building 10e� Q t construction and hereby authorize representatives of this County ISSUANCE FEE / to enter upon t e above mentioned property for InLsLpLLectwny , st, (C J �� ✓� 7�� ,LL��yLL� INVESTIGATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICAtION FOR BUILDING PERMIT I� COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL W BUILDING ADDRESS I hereby affirm that 1 have a certificate of consent to sell Insure BUILoI �. VAV ora certificate of VW"m Compensation I Ora copy thereof(Sec 9800 Lab C) �$. CITY ZIP 010780 LOCAIM polloy No . SIZE OF Lar No of BLOG8 NOW ole Lar 1w� G� ❑ Cerdfied copy Is hereby furnished NEAREST CROSS ST ❑ Certified copy is filed Wit;alp y building Inspection TRACT BLOCK Lar NO Lift USEZONE MAP NO department �f pDate ApplicantT . 1.� P OOO /!_ SPECIAL ONS o� CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER N b • �� TEL NO c� YES No COMPENSATION INSURANCE ` WITHIN 1000 FT OF SCHOOLS' ADDR688 (This es�needor dn be completed If the permit Is for one hundred 4 • LA 5' � DISTRICT GROUP CONST FIRE ZONE PROCEatiED By I cwft that In the performance of the work for which this permit CITY ' "P%91.1-up IP�1 1- � Is Issued I shall not employ any parson In any manner so as to AROHRECT OR ENGINEER TEL NO become Subject to the VAxkere Compensation Laws STATISTICAL t FICATWN APT CONDO Date-Applicant ADDRESS CLASS No �DWELL UNrrs NOTICE TO APPLICANT If after making this Certificate of RE12UIRED TOTAL SETBACK FROM EXIST Exemption you should become subject to the Workers 0 TEL NO SETBACK YARD HWY PROP LINE WIDTH Compensation praAslons of the Labor Code,you must forthwith ° FRONT comply with such provisions or this permit Shall be deemed revoked LIP L LICENSED CONTRACTORS DECLARATION CITY LIC Fj�s� Pict P L 1 hereby affirm that 1 am Iksrsed under provisions of Chapter 9 SEWER MAP (commencing with Section 700M of Division 9 of the Business and 80 FT SIZE NO OF STORES NO OF FAMILIES Professlomand In license Is in full force and efftct NEW ❑ BK Pe , liaerae Nu -Lie DESCRIPTION OF WORK ADD ❑ YAWAT10N Contractor G Date • • ALTER $ wo �� z 131 am exempt under Sec ' REPAIR ❑ S SPC for this reason DEMOL 13 LOMA PVC e Date • • USE of EXISTING BLDG URM ❑ riA Signature APPLICANT(PRINT) TEL NO LDMA FWM e r t T a ❑ I as owner of the property or my employees with wages as �°$ 4i. their sole compensation will do the work and the structure Is ADS POMDAM 0 not Intended or offered for Sale(Section 7014 Business and y T ProfaSelons Cods.) wILLTHEAPPLMWORFUTUREBUILDMOCCUgY PANDIEAHAZARDOUBM EMAL ❑ I a8 Owner Of ti>0 em exdu OR A MI%TBE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATM THAN �+ licensed contractors o rty amt the�y Cordrac; ng with PTHE AMOUNTAXPEDWIED Es❑ No ON TM HAZARDOUS WaBtlALs INIVINATION GURNIP P1NAI.BY / > �C�� g project (Section 7041 TLV/ Business and PrOfsStlOThs Ciode) WILL L THE INTENDED I=of THE BUILDING BY THE APPLxiMIT OR FUTURE BUILDING s i1 s�� OCCUP96WFMMUIREAPEFMMFORCONSTRUOrIONORLWOFI ATTONFROMThEecUTH CONSTRUCTION LENDING AGENCY �so��T MANAGEMENT T IscAOMIH SEE PERMITTING C EDIMIST y� 2 ITEM I hereby affirm filet there Is a constru slim lending agency for vre❑ wM � the performance Of the work for which this permit In Issued(Sec I WIVE � � - `�'2--�' -a ` TW SCACMD 3W civ C) n'TIN CHECKLIST UNDERSTAND MY REEOIa U TFORUffM GUIDE ATE LOSS ANGELES aD 400 Lender's Name HAZARDOUS MMA MMTYCODLWSFWC TNo3ANDFOROBTAININGAPERMTFRTOMMTHE80AMM CHCHECK � 0 Lenders Address ��� ° I certify that 1 have read this application and state#0 the above �y Information le correct I agree to comply with all county PC FEEAlf PERMITTEE Q�o 7 0000— i 7 a�•I G ordinances and State laws relating to building construction and Q hereby r�rof this p Spon Itsu""cE FES i At 8°i_ the above-�onea property for 7-6:' INVESTIGATION FEE TOTAL FEEly �. Q f/r.naNO�tsAT.• or Q M REYEItfE FOR EXPLANATORY LANGUAGE IWORKERT COMPENSATION DECLARATION hereby affirm that 1 have certificate of consent to self APPLICATION FOR BUILDING PERMIT insure or a certificate of Workers Compensation Insurance or a certified co thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No ZO 2Company49W.& BUILDING ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS �sr� ® Certified copy Is filed with the county building inspec BUILDING tion department C��j ADDRESS Date �Z licant_.L� a T Y zip LOCALITY NO OF UDGS NEAREST CERTIFICAE OF EXEMPTION FROM WORKERI SIZE OF LOT NOW ON LOT CROSS ST COMPENSATION INSURANCE (This section need not be completed if the permit is for one TRACE BLOCK LOT NO MAP BOOKR PAGE I PARCEL undyed dollars(;100)or less) OWNER ^4A. TEL NO s(!o LISE ZONE MAP NO I certify that in the performance of the work for which this permit is issued I shall not employ any person in any manner ADDRESS CONDITIONS SPECIAL a so as to become subject to the Workers Compensation Laws CONDIU CITY ZIP / ae Date Applicant ARCHITECT OR TEL DISTRICT GROUP FIRE BY O NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO ZONE V Exemption you should become subject to the Workers ! p Compensation provisions of the Labor Code you must forth ADDRESS N with comply with such provisions or this permit sholl be TEL qf( STATISTICAL CLASSIFICATION APT CONDO Z deemed revoked CONTRACTOR NO LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS---J I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NOS (commencing with Section 7000)of Division 3 of the Business LIC SEWER MAP ALLTAT and Professions Code and my license is in full force and effect CITY IV. INO CLASS CHECK BK PG VALIDATION License Number Lic Class C`'^+ SIZE STORIES FAMILIES ONE r— �7° oEscRlPnoN of WORK NEw ® vALUAnoN a 1 Il Ei'� Contractor 4+6AI f - ►moi- to � ❑ 110. TOTAL 97.54 ❑1 am exempt under Sec �'� T ALTER ❑ C6 97 54 B AP C for this reason USE REPAIR ❑ $/0/ fp Q � Me U11 Date EXISTING BLDG DEMOL ❑ ° Signature APPLICANT a iT O� 3 FINALDATE 15,11d 000D-W01 4/12/?1 OWNER BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor s License ; ti Law for the following reason (Section 7031 5 Business and ADDRESS �>D NNAL 6456 1 AM 1r Professions Code) NT By ❑ I as owner of the property or my employees with BUILDING � wages as their sole compensation will do the work and , the structure is not intended or offered for sale(Section LOCALITY 7044 Business and Professions Code) MOVING TEL ❑ I as owner of the property am exclusively contracting CONTRACTOR NO with licensed contractors to construct the project(Sec ADDRESS tion 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY IRID SET B YARD SAL NEFROM ExIST I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P L (Sec 3097 Civ C) SIDE .0 ' c 3> '"' [+1 ►` PL r Lender s Name y —t '`J "1 PC Fee$ Permit Fee tDNA Mf � • � Lender's Address 1 certify that I have read his application and state that the t� . Issuance Fee I-- ~� P/C# Pool above information eorre I agree to compply with all County Investigation Fee // �[ ordinances and St I elating to budding construction Total Fee 490;7• Perm # and hereby authori r ntatives of this County to enter upon the above rty for inspection purposes ,0 SEE REVERSE FOR EXPLANATORY -47 L/ iU7E ° V I Gti"i • Signature of Ap iicant or Agent Date tJ IT WORKERS COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT insure or a certificate of Workers Compensation Insurance or a certified co ..th))ere��of(Sac 3800 Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No,(dA[Z&Compony - 01 �� BUILDING i Certified copy is hereby furnished FOR APPLICANT TO FIL ADDRESS esl Certified copy is filed with the county building inspec BUILDING � tion department ADDRESS Date!�� 4pphcant CITY ZIP NEAREST EAREST ceRTIFi OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON WT N�►I T CROSS ST COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAS BOOK PAGE PARCEL hundred dollars($100)or less) TEL OWNER USE ZONE MAP I certify that in the performance of the work for which this INO permit is issued I shall not employ any person in any manner ADDRESS CO DITIONS It so as to become subject to the Workers Compensation Laws U CITY ZIP Date Applicant ARCHITECT OR TEL DISTRICT GROUP TYyFis IRE PROCESSED BY Q NOTICE TO APPLICANT If after making this Certificqte of ENGINEER NO Cf ZONE Exemption you should become subjed to the Workers p Compensation provisions of the Labor Code you must forth ADDRESS J with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO Z deemed revoked CONTRACTOR LOAAAH r9601=NO LICENSED CONTRACTORS DECLARATION UC CLASS NO DWELL UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS r( (commencing with Section 7000)of Division 3 of the Business LIC SEWER MAPd'IJ7f► and Professions Code and my license is in full force and effect CI Fr NO �0 CINO OF � C w BK PG VALIDATION License Number � ��7 6 � 1c Class SIZE STORIES FAMILIES ONE / VAWATION �!Contractor to DESCRIPTION OF WORK �y � $ Elam exempt under Sec L , ALTER ❑ B&P C for this reason REPAIR ❑ $ Date USE OF EXISTING BLDG DEMOL ❑ APPLICANT - TEL -�+ 9'] Signature (PRINT) NO 9 ( OWNER BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor s License 17 w. Law for the following reason (Section 7031 5 Business and ADDRESS FINAL j Professions Code) NT By AUT r a got I El as owner of the property or my employees with AADIDR� M7 1,0.60 wages as their sole compensation will do the work and LOCALITY ^ TYE � the structure is not intended or offered for sale(Section , 7044 Business and Professions Code) MOVING TEL ❑ 1 as owner of the property am exclusively contracting CONTRACTOR NO TOTAL 122-'60 with licensed contractors to construct the project (Sec ADDRESS CHECK 12�r611 tion 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY Ul REQUIRED SACK YARD HWY TOTAL SETBROP LIKEROM EXISTA r0U I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued PL (Sec 3097 Civ C j SIDE PL MW—OOO 1 5f V91 Lender s Name LDMA Ref 0 6766 1 AN 9:01 Lender's Address P C Fee$ �9 0 Permit Fee 10 fo ► I certify that I have read his application and state that the Issuance Fee IDAAA P/C# above information is corre I agree to comply with all County Investigation Fee ordinances and S to I cos lasing to building construction Total Fee O v TDMA Perm 0 and hereby authors ntatives of this County to enter upon the above it ry for inspection purposes Signature of lio cs ent Date / SO REVERSE FOR EXPLANATORY LANGUAGE • APPLICATION FOR BUILDING PERMIT COUNTY OF LOS AftEL* BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION FOR APPUCANT TO FILL IN BUILDI SS 1 hereby affirm that 1 have a certificate of consent to self insure BUILDIN GESS y or a certificate of Workers Compensation Insurance or a certified 0 copy thereof(Sec 3800 Lab C) C! T ZIP f��,/ 3L�(a / LOCALITY wPOIICy "►�"- Company--2 D SIZE OF NO OF BLDGS NOW ON LOT KCertfied copy Is hereby furnished NEAREST CROSS ST ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO department USE ZONE MAP NO Daler Dent �� ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEM ON FROM WORKERS OWNE TEL NO YES NO COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL (This section need not be completed d the permit Is for one hundred ADDR dollars($100)or leas) Tr 6Y A DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY I oertdy that in the performance of the work for which this permit CITY ZIP y Ia Issued I shall not employ any person In any manner so as to �� become subject t0 Workers Compeneat Laws CHITECT OR ENGINEER TEL NO C STATISTICAL C/LA�SS�IFICATK)N APT CONDO Kent ADDRESS CLASS NO S� DWELL UNITS NO TO A If a making this Certificate of ��+ REQUIRED TOTAL SETBACK FROM EXIST Exemption you *arid beco subject to the WorkersL NO ) SET BACK YARD MY PROP UNE WIDTH Compensation prowslons of the Labor Code you must forthwith aS FRONT comply with such provisions or this permit shall be deemed revoked ADDRE�515' C�O P L LICENSED CONTRACTORS DECLARATION (� SIDE fl(��' PI / UCC P L I hereby affirm that I am licensed uriderprovisions of Chapter 9 Z/� Ci SEWER MAP � (commencing with Section 7000)of Division 3 of the Business and SQ NO OF STORIES NO OF FAMILIES Professions Code nd 1 is in full force and NEW ❑ BK PG , O License Number Z— Lic Class WSCRIPnON OF WORK ADD ❑ VAUUMN V Contractor CAW f 61010C Date �� ALTER $ E3 am exempt under Sec r REPAIR E3 $ y �R H BgpC for this reason DEMOL 13LU U ]AAA P/C 4 � Date USE OF EXISTING t'C URM ❑ ^� H a.J Z Signature APPLJ (AWT) 1EL NO LDMA Perm F I11►41 s T ❑ 1 as owner of the property or my employees with wages eac � their sole compensation will do the work and the structure is AD 50..Nr I not Intended or offered for sale (Section 7044 Business and / FINAL DATE R 1 Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ❑ 1 as owner of the property am exclusrwdy Contracting with OR A MDnURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 2 1 licensed Contractors to construct the project (Section 7044 AMOUNTS SMOKED ON THE HAZARDOUS MATERIALS INFORMATION GUIDEI FINAL Bf Kc i NT Business and Professions Code) YES❑ NO 3303214■85 WILL THE I NDE USE OF THE SUIDUNG BY THE APPLICANT OR FUTURE BUILDING OCOUPMor REQUIRE A PERMR FOR CONSTRUCTION OR MOOIFICRION FROM THE SOUTH 'S j� CONSTRUCTION LENDING AGENCY COW Am QUALITY MANAGEMENT DISTRICT ISCAQW)SEE PERMITTING CHECKLIST FOR 2 a BS GUIDELINES. 1 hereby affirm that there is a construction lending agency for YES❑ NO 265.35 N the performance of the work for which this permit is issued(Sec TOTAL `p IH MEREADECKUST I UNDERSTAND EWRERRIALS IJE 0 UNDER THE OS THEANG LES COUNTY OPERMRTDE aECK 265.25 ING 3087 CIV C) CHECKLIST 1 uNt�RSTAND MY REQUIHEME UNDER THE LOS ANGELES COUNTY CODE TITLE 2 22 CTIONa 2 201 2 20140 OONCERMNG HAZARDOUS y Lender a Name MATER D Mfl A PEFMY IT FROM THE SCAOMD CHAIM .00 x$ Lender Address C O■!ER OR AdPT g I ceRdy that I have read this application and state under penalty PC FEE PERMIT FEE / 1 9/21,/9.7,of pequry that the above information is correct I agree to comply /) 91 cQi with all county ordinances and State lave relating to building !/ !/ et wua ■ • construction reby a representatives of this County ISSUANCE FEE O 1848 1 AM 9.11 t0 J�I�i� kled prgperty for i ( /ILS../ INVESTIGATION FEE TOTAL FEEAl. SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT C*tUff OF LOS ANGELES BUILDING AND SAFETY MIORIIER'S COMPENSATION DECLARATION FOR APPLICANT TO fq.L 06 BUILDNIG ADDRESS 9Z A �► 1 hereby affirm that I have a certificate of r m i n t to Safi Insure ING r • ' or a certificate of Workers Comperreation Insurance or a Certified t am theof Sec 3800 Lab C) CITY 21P ft re a LOCALITY � Pavy NO 1 W14b Company S'W!'C"Wp slzE of Lor no of BLohas NOW ON I.oT `❑ Certified copy Is hereby furnished -r Certified copy Is filed with the my building Inspection TRACT BLOCK LOT USEZONE ~NO sv Octad, , t APPIkWm ASSESSOR MAP BOOK RtitiE PARCEL SPECIAL COMDITIC R CERTIFICATE N FROM MIORKEPW ° � WAD •0M&. rJ vEs NO COMPENSATION INSURANCEL0,00'.14" wmtlN taco Fr of SCHOOL? t �191s fee onneedor dn be completed If the permit Is for one hundred • 'u DISTRICT GRo11P OONST FIREZONE PROCESSEDBY cITY �P 5.os 3 I certify that in the performance of time work for which this permit 140 Is Issued I shell not employ any Person In any manner so as to ARCNRECT OR ENGINEER TEL No become subject to the W orkere Compensation Laws BTxnurICAL CL�IFKXMON Date-Applicant ADDRESS CLASS NO DWELL UNITS NOTICE TO APPLICANT If after making this Certificate of REOUIRED TOTAL SETBACK FROM EXIST Exemption you should become subject to the Workers CONTRACTOELTE NO SETBACK YARD HWY PROPLJNE WIDTH Compensation provisions of the Labor Code you must forthwith "~ �.r FRONT oompy with such provisions or this permit shall be desrled revoked AODR�B LIC No PL LICENSED CONTm LIC CLAN SIDE PL 8 I hereby affirm that I am licensed under provisions of Chapter g SO Fr SIZE tW OF STORES NO OF T�11ttIU� SEWER MAP v (commencing with Section 7000)of Division 3 of the Business and cc Professlors and I Is In full force aid o..T", N� ❑ � � ► �-+ DESCRIPTION OF WORK ADD ❑ vALUAT" ••3 License Number Lic Clew Contractor Data • ALTER $ �O J tC v _W 13I am exempt under Sec ° • REPIAIR 131 $ �+- � 7J #-' B VC for this reason DEMOL 13LOMA P/O r 1 I TE31`, Date use of EXISTINGBLm URM ❑ }1 tgi G•IL! 73. 13 samdure APPLICANT OMM TEL No LIMA Poems CHECK 72: 13 ❑ I as ownerFe property or my empla ess with wages as their solerXr will do the work and the structure Is ADDRESS CHANGE 03 not imendedm�for sale (Section 7044 Business and � PTOfAslIOn6 Code) wILLTNEAPPUGwranwTLIFEWsAw000alPnNTMNMAHAZARDMMMXn IAL ❑ I as owner of the am exclusively contracting with T A rrNUNM CONN SD O A HAZARDOUSVOO MMMERU WNL M OR eAEIIrBh THAN PAY n9 THeAMouNre aPeaphM ON ThE NASARDOus MATHeALBIiPDRMArION oulDer ANAL BY 1 1� r ����"��� 7/14/92' Blsiness ProfeesiIlro an' contractors to Construct Code) the Pmt (Section M4 ves 13 No❑ �} �IL4 13 I AM 8 1 l WRL THE WINDED USE OF That BUILDING Elf THE APPLICANT OR Fun=suLom ODOLWAWPEOUMCONSTRUCTION LENDING AGENCY COW AM o Ai ANNUSS rWDlarnCT G eff PWWffM 04WLW /�� FCRGWDWMM A{�T°9$ I hereby affirm that there Is a construction lending agency for =❑ No❑ the Cance of the work for which this permit Is Issued(sec � a 1z ti $ WU civ ) IPBifMITrINQ CHWAD O KLIUST RODUS Wa1 01MAW Mr REpu�1 TAND HE LOS AI 7 i Lenders Name HA DoCOUNTY M&tffE WTffLE R.eR aRnh'�K#MD20 �"KMOO�NGAr�gAR� 1 ITEMS ^ UmdersAddrese •,,,a,�,,,,,,r TlITAL 101-5.94 4 0 I car*to I have read this application and state that to show► �1 �+ 105.94 Information Is correct I agree to comply with all county PC FEE 73 13 PERMIT FEE t CHECK ordinances and Stele Iowa relating to building Construction and '-h WOW authorize�off t6��� upon N38UANCE FEE � � (HAN3E U0 166 1-WIM202 _.14-q t. INVESTIGATION FEE TOTAL FEE Of;, S!E REVS=MR EIMLAN MM LANOItIAGB 4411 1 All F°17 WORKERS COMPENSATION DECLARATION APPLICATION FOR BUILDING PERMIT 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(Sac 3800 ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No 11 -ftpo y ~ • n BUILDING ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county budding inspec ADDRESS 2 tion department 7L�7ii • OAK 49T. mtm" !2EU Date %%9.51 Applicant CITY H ZIP Q LOCALITY CERTIFICATE OF EXEMPTIOA FROM WORKERS SIZE OF LOT WO �' 6i N LOT C Tg („&S COMPENSATION INSURANCE (This section need not be completed if the permit is for one TRACT � 6 BLOCK LOT NO MAP BOOKASSESSOPAGE O PARCEL V hhundred dollars($100)or less) TEL OWNER USE ZONE MAP I certify that in the performance of the work for which this C I.r SPECIAL y permit is issued I shall not employ any person in any manner ADDRESS CONDITIONS ^ so as to become subject to the Workers Compensation Laws at- 8 CITY ZIP V Date Applicant ARCHITECT OR TEL ad NOTICE TO APPLICANT If after making this Certificate of ENGIN 1�A NO DISTRICT GROUP NST ZONFIRE PROCESSED BY Q Exemption you should become subject to the Workers '/ Compensation provisions of the Labor Code you must forth ADDRESS �� /Z !' 3 with comply with such Z p y provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO deemed revoked CONTRACTOR NO LICENSED CONTRACTORS DECLARATION UC CLASS NO DWELL UNITS I hereby affvm that 1 am licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP (commenting with Section 7000)of Dtwsian 3 of the Business LIC and Professions Codi and my license ism full force and CITY CHECK �� BIC PG VALIDATION License Number 5557 Lic Class_ SIZE STORIES MIMIl1l51 YNR ONE GDate ❑ VALUATION Contractor M�N� -044 DESCRIPTION OF WORK NEW ; 1s p�a • ❑1 am exempt under Sec 701594017ADD +u ► ALTER ❑ B 8P C for this reason 9 USE OF g REPAIR ElOEM $ • EXISTING BLDG OEMOL ❑ Signature kriAPPUC NTT TEL FINAL O ER BUILDER DECLARATION (PRDATE /z I hereby affirm that I am exempt from the Contractor s license Law for the following reason (Section 7031 5 Business and '� FINAL Professions Code) PRESENT By WILD131 as owner of the property or my employees with Ij ESS ��'��O T wages as their sole compensation will do the work and the structure is not intended or offered for sale(Section LOCALITY , `�`� uy i 7044 Business and Professions Code) MOVING TEL i ❑ 1 as owner of the property am exclusively contracting CONTRACTOR NO with licensed contractors to construct the project(Sec ADDRESS ACCT.v tion 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY UII�D YARD HWY T Al FROM IST w � I hereby affirm that there is a construction lending agency for FRONT 2 IMS the performance of the work for which this permit is issued P L (Sec 3097 Civ C) SIDE TOTAL 97.00 PL Lender s Name rcHEcr 57 OD PC Fee E Pe dV rmit Fae � Ref N u �� Lender s Address �+� + -OU o I certify that I have read this application and state that the Issuance Fee / LDMA P/C ft above information is correct 1 agree to comply with all County Investigation Fee Ii�n ordinances and State laws relating to budding construction Total Fee LDMA Perm N � / � � and hereby authorize representatives of this County to enter upon the mentioned p ,party for inspection_purposes $I3 IM 9a'; n G�— dj• 9) =REVERSE FOR EXPLANATORY LANGUAGE ignature of Applicant or Agent Date r s WORKERS COMPENSATION DECLARATION hereby a certificate that I have certificateomconsent to self APPLICATION FOR BUILDING PERMIT insure or a tificate of Workers Compensation ation Insurance or a certified co the of(Sec 3800 La C) COUNTY OF LOS ANGELES BUILDING AND SAFETY Polity No mpony BUILDING ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS 12 Certified copy is filed with the county building inspec BUILDING / — tion department ADDRESS D �/ Date � /Applicant�l� CITY ZIP TY NEAREST S ST �3 CERTIFI TE OF EXEMPTION FROM WORKS SIZE OF LOT �ON LOT COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK I LOT NO MAPF BOOK I PAGE I PARCEL hundred dollars($100)or less) TEL USE ZONE MAP OWNER I certify that in the performance of the work for which this / n permit is issued I shall not employ any person in any manner ADDRESS �i�/' �NDIITTIONS a so as to become subject to the Workers Compensation Laws O ClTY zip .C:K'a Date Applicant ARCHITECT OR TEL gISTRICT GROUP TYPE FIRE PROCESSED BY Q NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO CONST QNE Exemption you should become subject to the Workers' y' 3 Compensation provisions of the Labor Code you must forth ADDRESS with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFI TION APT CONDO h deemed revoked CONTRACTOR NO Z LICENSED CONTRACTORS DECLARATION UC CLASS NO LL UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS SEWER MAP (commencing with Section 7000)of Division 3 of the Business C and Professions Code and my license is in full force and effect CI FT NO OF o NO OF C� CHECK BK PG VALIDATION License Number 1c Clan SIZE STORIES FAMILIES ONE oo// / IIvv11 VALUATION Contractor 1 to DESCRIPTION OF WORK NEW J'I ; P El1 am exempt under Sec ADD ❑ lop.❑ B&P C for this reason REPAIR ❑ $ Date IUSE DCISTIING BLDG DEMOL ❑ Signature APPLICANT TEL NO OWNER BUILDER DECLARATION (PRINT) FINAL r3 DATE I hereby affirm that I am exempt from the Contractor's License +� Law for the following reason (Section 7031 5 Business and Z--Af FINAL CCT.a Professions Code) PRESENT my ❑ I as owner of the property or my employees with ADDR� ` 3W7 K 69 wages as their sole compensation will do the work and , LOCALITY the structure is not intended or offered for sale(Section } 7044 Business and Professions Code) MOVING TEL ❑ I as owner of the property am exclusively contracting CONTRACTOR NO ACCT. Or with licensed contractors to construct the project(Sec ADDRESS 3,307 70.371 tion 7044 Business and Professions Code) UIRED CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOTAL� LINESETBAFROM JDTH-EXIST + ITEi'!5 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 TI ITAL 104.07 (Sec 3097 Civ C) SIDE EHEC K 101x.137 Lender's Name / t�w� E PC Fee E •6 Perms Fes LDMA Ref # CHAh(GE .[I[I Lender's Address ► o I certify thatAhth6ishcation and state that the Issuance LDMA P2# d- 1 �f1891 above informo com�ly with all County Investigation Fsaordinances ao bui ding construction Total Fee LDMA Perm # and hereby f this County to enter 9071 AM i�1L upon the abfo spection purposes �f n $111 REVERSE FOR EXPLANATORY LANGUAGE Signa ure of I nt or Agent Date a APPLICATION FOR BUILDING PERMIT �1 COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FM APPLICANT TO FILL W BUILDINGADDRESS 1&9,2& MAKAVIL I hereby afitrm that I have a certificate of consent to eefi Insure BUILDING or a ar"Up ats of Ylbrkere Compensation Insurance or a certllied copy low (sec 3900 Lab C) WNW MJlNA�L CITY O! ZtP .91'� LOFTY Policy Company.L Its, DO. a=OF LOT No OF BLDGa NOW ON LOT G Certified copy Is hereby furnished NEAREST CROSS 8T LAO in"S ElCertified copy is filed with the county building Irsfpe tion ASSET BLOCK LOT NO USE ZONE MAP NO 00,/ s deparbnerlt • �J Dale • vy li ant VP.MBOOK PAGE PgRC0�0� qm* 9 SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKER8' OVIINER • � �� ' • d� YES NO COMPENSATION INSURANCE WITHIN 10W Fr OF SCHOOL? ADDRESS .�y� DISTRICT GROUP CONST FIRE ZONE PROCESSED BY (Thio section need not be completed ti the permit b for one hundred � i v�y dollars(6100)or lea) Crrr aP I cerdy do In time performance w tier work for which this permit vs I T� ��� � 2 too", Is leveed I Shall not employ any person in any manner so es tD1ARW_W;rJEER TEL NO CU1881t1CAT10N v APr CONDO become Subject to fln Workers Compensation Laws ��L/ Ode—Apples ADDRESS CLASS NO C92 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 HM PROP LINE WIDTH Compensationprovisions of the Labor Code you must fortimvritlmgas a As • FRONT comply with such provisions or this permit shell be deemed revoked ADDRu -7 PL 'V"S ?7 LICENSED CONTRACTORS DECLARATION I CITY P l I hereby e(flrTn that I am IkeeTeed under provisions w Chapter 9 SAO s0 Fr 8 NO OF STORES NO OF FAMILIES N ❑ SicPO (commencing with Section 700M of Dlvlelon 3 w Bre Suelnea and Professions Code and license b in full force ► LicenseNumbermdpSaw rS clap DESCRIPTION OF WORK ADD ❑ YALUATtON contractor Date Gi. .J2 • ALTER ❑ I am exampt under Sec REPAIR ❑ s B&PC for this reason DEMOL 13LDIAA PAC e Date O Z. USE of EXISTING BLDG URM ❑ 23 Signature APPLICANT PVW►rl TEL NO t�MA Pminn• ❑ 1 es owner properly or my employees with wages a gZ ACC T.,Ar ADDRESS not I tended or offered fora sale(SSecction rk�aBusiness ars FWAL DATE ` 307 48.79 o Protesters Code) ws,Lrns•PwCurronFunlnaeuLaNsaccuwNrWMEAnA:AnoMwTeluu. ❑ I es owner,Of the em ORA�CONVSIM A HAZARDOUS MATERNL EQUAL TO OR eREJM THANproperty e7anw*Contracting with TIeUWONTHEHAZAMMMNBMWWPCMUM OUMV FINAL BY > ACCT.Blicensed contractors to Construct the project (Section 70" YES Business and ProfeveloneT Code) WILL THE=ENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE IRRULOMMO 3307 42O$ OOCUPRNrRIE3O{I�APBa6TPORCONSTRUCTION ORMODIFIGmONFROMTHESOUiN CONSTRUCTION LENDING AGENCY CQAkST aI QUALITY MANAGOMM DISTRICT a'ROM SEE PEWffM 04MMW FOR A I hereby affirm that there is a construction lending agency for res 13 No ,` ACCT.: the performance of the work for which this permit Is Issued(Sec I HNIE READ THE HAZARDOUS MATERIALS INFORMATION CUM AND THE SCAOMD 3097 Civ C) PB NITTINo C ECKL sr I UNDEAdHE UMN eND MY REQUIREMENTS UNDER TANBEtss 3307 474 376 Lenders Name FVZAATRDYMWM 8RBKMuo OBM17►I'NMAPERIar�flq'AMT VOID Lenders Address o I oertiy that I have read this application and State timet the above 3307 —474.39 Informatlam Is Correct I agree to comply with all county ordinances and State lows relating to building cors bucdlon and Pa RI E ✓ PERMIT FEE �Op ITEMS eauftdn oftCmytoeup d� ISSUANCE FEE TUTAL 474.39hereby b re property for MMESTIGArION FEE TOTAL FEE CHECK 474 39 ftNWMd'~Qrft" °" CHANGE .00 eEE REVEM POR MUNJ NATM LANOYAOE WORKERS COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT insure or a certificate of Workers Compensation Insurance or a certified copy thereoff(Sec 3800 C)ow COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N�� G �a>rompany ElCertifiedcopy is hereby furnished FOR APPLICANT TO FILL IN ,MOM T F-1Certifiedcopy is fled with the county budding irtspec BUILDING ADDRESS S • tion department it + Date .17 b,a t Applicant CITY GI zip01"2465O LOCALITY 1� +�•��.! c CERTIFICATE OF EXEMPTIO FROM WORKERS SIZE OF LOT O Sd •NOW O B LOT CROSS ST lS /OIJA S COMPENSATION INSURANCE p (Thts section need not be completed if the permit is for one TRACT �� BLOCK LOT NO AAAP BOOK PAGE O 7 PARCEI�Op F�undyed dollars($100)or less) OWNER Mi .1 USE ZOIC MAP O !�{ N • N I certify that in the performance of the work for which this (,�C,,,,' 'SUN, �„ permit is issued I shall not employ any person in any manner ADDRESS CONDIITIONS a so as to become subject to the Workers Compensation Laws , L zip u CITY 4TWO Date Applicant ARCHITECT OR TEL NOTICE TO APPLICANT If after making this Certificate of ENGINEER „'.VQ '1- NO DISTRICT GROUP COFI SED BY O Exemption you should become subject to the Workers ITYPE RE . ! 1 Compensation provisions of the Labor Code you must forth ADDRESS V J with comply with such provisions or this permit shpjl be TEL STATISTICAL CLASSIFICATION APT CONDO deemed revoked CONTRACTOR NO Z LICENSED CONTRACTORS DECLARATION UC CLASS NO DWELL UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDS NO SEINER MAP (commencing with Section 7000)of Division 3 of the Business LIC and Professions Code and my license is in full force anieffect CITY CLASSBKPG VALIDATION I NO OF INO CHECK License Number 5swi* I _lic Cl SZE� STORIES I idiAAiilE6 ONE DESCRIPTION OF WORK NEW ❑ VALUATION ContractorIAIIJ& CALr� Dafe A� ❑ 5 40 60 s'�+ ❑I am exempt under Sec y ► ALTER ❑ B&P C for this reason ElUSE OF _ Dote EXISTING BLDG DEMOL ❑ Signnf,�re APPLICANT TEL FINAL NER BUILDER DECLARATION (PRINT DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5 Business and ADDRESS FINAL i Professions Code) By A. ❑ I as owner of the property or my employees with ADDRESS AL L I•T wages as their sole compensation wdl do the work and LOCALITY , r 7 �.�+.� the structure is not intended or offered for sale(Section 7044 Business and Professions Code) MOVING CONTRACTOR IEL f YiEi ❑ I as owner of the property am exclusively contracting with licensed contractors to construct the project(Sec ADDS + TOTAL 70®38 tion 7044, Business and Professions Code) M CONSTRUCTION LENDING AGENCY SET IRED YARD HWY TOTALPROP LIN SETBOCK ROM I `NEG 70,,-8 I hereby affirm that there is a construction lending agency for FRONT _ CNAWE Qj Id the performance of the work for which this permit is issued P L t; &c 3097 Civ C) SIDE PL , lr Lender's Name 0000-0001 7/16/91 LDAAA Ref N P C Fee Permit Fee 8027 f AM 7 L*4 Lender s Address rU' oI certify that I have read this application and state that the Issuance Fee O'J� TDMA P/C R above information is Correct I agree to complywith all CountyInvestigation Fee ordinances and State laws relating to buildig constructioTotal Fee TDMA Perm M and hereby authorize representatives of this County to enter upon the abov&mentioned property for inspection purposes •1 i SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date l APPLICATION FOR BUILDING PERMIT r COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS 1 hereby affirm that I have a Certificate of consent to self unsure BUILDING ADDRE or a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) I CITY ZIP LOCALRY Policy No biuu- Paty SIZE OF LOT NO OF SLDGS NOW ON LOT ❑ Certified copy IS hereby furnished NEAREST CROSS ST ❑ Ciertlfled Copy Is filed With the County building Inspection TRACT BLOCK LOT NO department USE ZONE MAP NO Dateu-2.41 Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTTFK;ATE OF EXEMPTION FROM WORKERS OWNER TEL NO NO COMPENSATION INSURANCE R WITHIN 1000 FT OF SCHOOL? YES (This section need not be completed if the permit G for one hundred ADDRESS dollars($100)or less) 404k DISTRICT GROUP TYPE FIRE ZONE PROCESSED BY t certify that In the performance of the work for which than permit CITY ZIP Is Issued I shall not employ any person In any manner so as to ARCHITECT OR ENGINEER TEL NO O� become subject to the Workers Compensation Laws SL4TISTICAL CLASSIFICATION APT CONDO Dam Applicant ADDRESS CLASS NO DWELL UNITS A0710E 70 AARJC4NT 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 forthwithCIP 6 ('b FRONT comply with such provisions or than permit shall be deemed revoked ADDRESS LIC N P L LICENSED CONTRACTORS DECLARATION SIDE CRY LIC LASS P L I hereby affirm that I am licensed underprovlswns of Chapter 9 3 SEWER MAP } (commencing with Section 7000)of Dnnsson 3 of the Business and SO FT SIZE NO OF STMES I NO OF FAMILIES NEW ❑ BK PG d Professions Code and my license Is In full force and effect ► O QLicense Num LID Class DESCRIPTION OF WORK ADD 13MILUAION Contractor ,Date ALTER ❑ $ 1 0 O ❑ I am exempt under Sec REPAIR ❑ $ W B&PC for this reason DEMOL ❑ Date USE OF EXISTING BLDG URM E3LDMA P/C* Z Signature 'I APPLICANT(PRINT) TEL NO LDGAW PlEtrm ❑ 1 as owner of the property or my employees with wages as Z their sole compensation will do the work and the Stnkture as ADDRESS �y7 55.2- — not Intended or offered for sale(Section 7044 Business and FINAL DATE ti7JLhr Professions Code) WILL THE APPLICANT OR FUTURE Bull OCCUPANT HANDLE A HAZARDOUS MATERIAL ❑ I as owner Of the property am exclusively contracting with OR A MIXTURE CONWNNG A HAZARDOUS MATERIAAL EQUAL TO OR GREATER THAN THE a 1 licensed Contractors to construct the project (Section 7044 AMOUNTS SPECIFIED E3 ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY ACCT.T Business and Professions Code) WILYESL ❑ NO❑ WLL THE INTENDED USE OF THE BUIDLNG 9Y T1E APPLICANT OR FUTURE eUILDING20r ��S 105.20 OCCUPANT FIEOIARE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MAWGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. �. ITEl1s I hereby affirm that there Is a Construction lending agency for YES❑ No❑ W the performance of the work for which this permit Is Issued(Sec IH ME REM THE HAZARDOUS MATERIALSNFORMAATIONGUIDEANDTHESCACMDPERMiTTNG TOTAL 160.53�• N 3097 Cw C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE MCK �' TITLE 2 CHAPTER 2 20 SECTIONS 2 20100 THROUGH 2 20 140 CONCERNING HAZARDOUS 160 Lenders Name MATERIALS REPORTING AND FOR OMNNG A PERMIT FROM THE SCAOMD .00genders Address 0 Q 1 Certify that I have read the application and state under penalty OWNER OR AGENTPC FEE PERMIT FEE 41140 .., s of perjury that the above Information Is correct I agree to comply / D-cool 11/ 3/4 XI with all county ordinances and State laws relating to building p( C construction and hereby auftnze representatives of this County ISSUANCE FEE / �� X414 1 AP(10:�5 to anter upon the above menu property for Inspection purposes 10 INVESTIGATION FEE TOTAL FEE AO �a toor+n oe. SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT �] COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER S COMPENSATION DECLARA71ON FOR APPLICANT TO FILL IN BUILDING ADDRESS Avy I hereby affirm that I have a cerhflcate of consent to self Insure BUILDING O or a certificate of Workers �Coompensation Insurance or a certified p I + (See 3800 e��3S e b C)�, o 9 CITY � " 23PLOCALITY 13 Certified copy is hereby furnished ��� iTt SIZE OF LOT NO OF BLDGS NOW ON LOT ' NEAREST CROSS ST (KCertified copy is filed with the county building Inspection TAT BLOCK LOT NO department USE DINE MAP NO w� Date Applicant .Y 1 ASSESSOR MAP BOOK R�aE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMP71ON FROM WORKERS OWNER TEL No COMPENSATION INSURANCE S WITHIN 1000 Fr OF scHooLT YES NO ESS(This section need not be completed it the permit is for one hundred �� - r DISTRICT GROUP TY IRE ZONE PROCESSED BY dollars($100)or less) I certify that In the performance of the work for which this permit CITY ZIP p is Issued i shall not employ any person In any manner so as to ARCHITECT OR EIRANEER TEL NO �NtI become subject to the Workers Compensation laws STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO DWELL UNITS NODE TO APPL(C41YT ff atter 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 preview* of the Labor Code you must forthwith rd 12 A4, . J LJ FRONT comply with such provisions or this permit shall be deemed revoked ADDRESS—, LIC NO PL LICENSED CONTRACTORS DECLARATION a PL SIDE 1 hereby affirm that I am licensed underprovisions of Chapter 9 CRY M 6iv 1 LC CLASS ad SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ FT SIZE NO OF STMIES NO OF FAMILIES >, Professions Code and my hgo Is In full force and effect NEW E3 BK PO ► D. i( DESCRIPTION OF WORK License Number UO Class 96 ADD ❑ V VALUA71oN Contractor to ALTER ❑4116A1191 (h4k e4" - Q ❑ 1 am exempt under Sec REPAIR ❑ $ B&PC for this reason DEMOL ❑ uXMa Pic• W Date USE OF EXISTING BLDG URM ❑ N Signature APPLICANT(PRINT) TEL NO LDMA Perm i 23 Z ❑ I as owner of the property or my employees with wages as C ACCT.their sole compensation will do the work and the structure is ADDRESS AT not Intended or offered for sale (Section 7044 Business and FINAL DATE 0 3M7 50.11 Professions Code) VRLL THE APPLICANT OR FUTURE aURDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ❑ 1 as owner of the property am exclusively Contracting with OR A MIXTURE CONTANNING A HAZARDOUS MATERIAL EQUAL TD OR GREATER THAN THE a 1 AMOUN78 SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY IlCeraed contractors t0 construct the protect (Section 7044 9 Business and Professions Code) WILL YES13 No 13A=.f VMTHE INTENDED USE OF THE BUIDG BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 3307 102.30 CONSTRUCTION LENDING AGENCY COAST GUIDELINES.AIR MANAGEMENT DISTRICT(sCNOMD)SEE PERMITTING CHECKLIST FOR I hereby affirm that there is a txxlstructLon lending agency for MS YES 13 No E32 IT 152.80+'y • a the performance of the work for which this permit Is issued(See IWMEREAD THE HAZARDOUSMATERIALSNNFORMATIONGUIDEAND 7HESCAQMDPERMITTING TOTt .L i O a 3097 Civ C) CHECIXLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE 04 TITLE 2 CHAPTER 2 20 SECTIONS 2 20100 THROUGH 2 20 140 CONCERNING HAZARDOUS //��// �y i Lender a Name MATERIALS REPORTING AND FOR OSVJMNG A PERMIT FROM THE SCAOMD /���yn 1M.D o Lenders Address GOR .00 0 ow.En OR AGENT g I Certify that I have read this application and state udder penalty PC FEE D PERMIT FEE / of perjury that the above Information Is correct I agree to comply (/ ?4 with all county ordinances and State laws relating to building �9 r 1 4� construction and hereby authorize representatives of this County ISSUANCE FEE ��� to enter upon the a ment red property for Inspection purposes 9314 1 AM 9:49 INVESTIGATION FEE TOTAL FEE .!pea TIP a aAWEDae + •7 SEE REVERSE FOR EXPLANATORY LANGUAGE r APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKERS COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self msure BUILDING ADDRESSA. '� or a Certificate of Workers Compensation Insurance or a certified CITY P copy thereof(Sec 3800 Lab C) 1 LOCALITY Policy NO 0�L2.-Ng Company V� SIZE NO OF BLOGS NOW ON LOT TIEVA pi-see .4 qr-r ('Ceddled copy is hereby furnished NEAREST CROSS ST ❑Caddied copy is filed with the county building Inspection TRACT BLOCK LOT NO departnrent USE ZONE MAP NO DateApplicant ASSESSOR MAP BOOK RAGE PARCEL I SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS OWNER TEL No COMPENSATION INSURANCE A* I G WITHIN 1000 FT OF SCHOOL? vEs No (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 1 certify that in the performance of the work for which this permit CRY 1 Ars, ZIP is Issued i shall not employ any person in any manner so as to i� —Z .a X,.,o become subject to the Workers Compensation Laws ARCHITECT OR ENGINEER TEL NO Sro►TISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO 19 12 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 SETBACK YARD HWY PROP UNE WIDTH Compensation provisions of the Labor Code you must forthwith I ( FRONT comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO PL iSG&I 311II&VSIDE LICENSED CONTRACTORS DECLARATION CITY LIC CLastP 1. I hereby affirm that I am licensed underprovisione of Chapter 9 1 ~ SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO FT SIZE NO OF STORIES NO OF FAMILIES NEW 13 BK PG , d Professions Code and my license Is in full force and effect License Number !► j? Lie Class C. �� DESCRIPTION OF WORK ADD ❑ vA AMON w O Contractor Date V+—I��Q1ALTER ❑ $ V Q ❑ 1 am exempt under Sec REPAIR ❑ $ SBPC for this reason DEMOL ❑ LOMA PRC# W Date USE OF EXISTING BLDG URM ❑ n co Signature APPLICANT(PRINT) TEL NO LDMA Form• 23 Z ❑ 1 as owner of the property or my employees with wages as C ACCT A their sole compensation will do the work and the structure is ADDRESS y�� not Intended or offered for sale (Section 7044 Business and FINAL DATE C 7 42.72 Professions Code) WILL THE APPLICANT OR FUTURE BULDING OCCUPANT H MxE A HAZARDOUS MATERIAL ❑I as owner of the property am exclusio* contracting with OR A MIXTURE CONWNING A HAZARDOUS MATERIAL EQUAL TO OR GREATER TWIN THE licensed contractors to construct the project (Section 7044 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERL"INFORMATION GUIDE? FINAL BY > ACCT. Business and Professions Code) YES❑ No❑ WILL THE INTENDED USE OF THE SUIDLM6 BY THE APPLICANT OR FUTURE 13UILDING 7 . OCCUFANT REOUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 70 CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT(SGAOMD)SEE PERMITTING CHECKLIST FOR eA GIADEUNER L ITM I hereby affirm that there is a construction lending agency for YES[] No❑ a the performance of the work for which this permit is Issued(Sec I HM I*"THE HAZARDOUS MATERIALS INFORMAnONGUIDEAND THE SCAOMDPERMITTING MAL 129.42 N 3097 CIV C) CHECKLIST I UNDERSTAND MY REOUIREMENTS UNDER THE LOS ANGELES COUNTY CODE �/ �p TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS "CK W.42 Lenders Name MATERIALS REPORTING AND FOR OBWMNG A PERMIT FROM THE SCAOMD 0 Lenders Address •� c awMA OR nGENr 1 certify that I have read this application and state under penalty 8 of perjury that the above information is correct I agree to comply PC FEE _7" PERMIT FEE / o —=I 4/ 5/93 a with all county ordinances and State laws relating to building p{ wee ria construction and hereby authorize representatives of this County ISSUANCE FEE ��` ! Aja 1 1�' g:to to enter upon the above mentioned property for inspection purposes (Dem �v�a� o nnr INVESTIGATION FEE TOTAL FEE gO A eWOM a MOMM«fWr � V SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT ] COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS 1 hereby affirm that I have a certificate of consent to self insure BUILDING ADDR ss A S 2 or a certificate of Workers Compensation Insurance or a certified ro copy thereof(Sac 3800 Lab C) CITY ZIP JPolicy No Qf,2nEa& Company, SIZE LOT NO OF SLOGS NOW ON LOT LOCALITY ❑ Certified copy Is hereby furnished —�� NEAREST CROSS ST departine[3 Certified copy a filed with the county building Inspection TRACT BLOCK LOT NO nt ZONE MAP NO Date , �O Applicant_ ASSESSOR MAP BOOK RAGE PARCEL 41 3PECUIL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS OWNER TEL No YES NO COMPENSATION INSURANCE � WITHIN 1000 FT OF SCHOOL? (This section need not be completed If the permit is for one hundred ADORES DISTRICT GROUPTYPE CONST FIRE ZONE PROCESSED BY dollars($100)or less.) A& hd-14112- CRY ZIP I certify that in the performance of the work for which this permit TEL NO Is Issued 1 shall not employ any person In any manner so as to ARCHITECT OR ENGINEER ® b� become subject t0 the Workers Compensation Laws STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO A DWELL UNITS NO`nW TO APPLICANT If after making this Certnccate of REQUIRED TOTAL SETBACK FROM EXIST EXemptlon you should become subject to the Wbrkers CONTRACTOR TEL O SET BACK YARD MY PROP LINE WIDTH Compensation provisions of the tabor Code you must forthwith 4WoJ CA ►( 1 40 comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO FRONT 1. 00eLICENSED CONTRACTORS DECLARATION SIDE CRY LIC CLASS � P L I hereby affirm that I am licensed underprovlsions of Chapter 9 ► SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SIZE NO OF STORIES NO OF MRIES Professions Code and my Ilcetnnise Is in full force and effect NEW ❑ BK PG ► d License Number Vy i Lac Class DESCRIPTION OF WORK ADD 13 WILUATION R O Co ntractor Date 8 ALTER ❑ $ `�m r !Y ❑ I am a empt u r REPAIR E3 $ B&PC for this reason DEMOL ❑ LDMA PRC# W Date USE OF EXtS TING BLDG URM ❑ 23 �- Signature APPLICANT fPRWT1 TEL NO LDMA Perm a Z ❑ 1 as owner of the property or my employees with wages as Z ACCTA their sole compensation will do the work and the structure is ADDRESS 07 42.74 not Intended or offered for sale (Section 7044 Business and FINAL DATE 1 Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL If ❑ 1 as owner of the property am exclusively Contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EOUAL TO OR GREATER THAN THE licensed contractors t0 construct the project (Section 7044 AMou,na SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY y YE8 13 No 0T•T Business and Profession Code) WILL THE FUTURE BUILDING OCCUPANT REOIARE A�PERMIT FOR CONSTRUCTION OR MODIFICATIOE OF THE 13UIDUNG BY THE APPLICANTONN FROM THE SOUTH 3307 86.70 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCARMD)SEE PERMITTING CHECKLIST FOR �TG IO GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ Np❑ a the performance of the work for which this permit Is Issued(Sec TOTAL 129.44 a 3097 CN C) CHEECCKLISf NDER MY F EREAD THE HAZARDOUS OIA�REMENTS UNDER THERMATICIN E THEANGELES COUNTY M� / /y► ��p Lender a Name M�PoUS REPORTING ACHAPTER 2 20 ND FORK OffMIN20 G A PERMIT THROUGH 2FROM THE SCAOMD 140 CONCERNING HAZARDOUS ty�TUT6Gwyun� jrj,7.�' Lenders Address .00 o OMM CA ADEM S 1 certify that I have read this application and state under penalty PC FEE PERMIT FEE of pequry that the above Information is correct I agree to comply r1 � // D� 0000-0001 4/ 5/973 with all county ordinances and State laws relating to building OFA �o construction and hereby authorize representatives of this County ISSUANCE FEE r t to enter upon the above mentioned property for inspection purposes Q� �p.Ii 9W 1 AN 9:27 n -1 INVESTIGATION FEE TOTAL FEE / '' &.apps d Ap~jt�T e.A0 1 (O SEE REVERSE FOR EXPLANATORY LANGUAGE ,4bs APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION 1 FOR APPLICANT TO FILL IN BUILDING ADDRESS �� I hereby affirm that I have a certificate of consent to self Insure BUILDING ADDRESS or a certificate of Workers Compensation Insurance or a certified R, 91 TV) copy thereof(Sac 3800 Lab C) C 'TmQk CA ZIP Policy No 1 �7 6��r9� Company w SQE OF LOT NO OF BLDGS NO LOT LOCALITY ❑ Certified copy is hereby furnished NEAREST CROSS ST ❑ Certified copy is filed with the county building Inspection TRACT BLOCK LOT NO department USE ZONE MAP NO / g, .6b ^: ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS \ OWNER L NO COMPENSATION INSURANCE M— M V0-in WITHIN 1000 FT OF SCHOOL? YES NO (This section need not be completed d the permit Is for one hundred ADD DISTRICT GROUP TYPE CONST FIRE ZONE PROCffiFWD BY dollars($100)or lesa.) I certify that in the performance of the work for which this perm" —460 'Is.Of Is Issued I shall not employ any person In any manner so as to wt 6�u ARCHITECT O ENGINEER TEL NO become subject to the Workers Compensation Laws STATISTICALCATION APV 1050*60 Date Applicant ADDRESS CLASS NO J IDWELL UNITS N0710E 70 APPLICANT if after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption you should become subject to the Workers CONTRACTOR TEL NOa�. SET BACK YARD MY PROP LINE WIDTH Compensation provisions of the Labor Code you must forthwith 3 L% FRONT comply with such provowns or this permit shall be deemed revoked AD ESS LIC tt NO P L LICENSED CONTRACTORS DECLARATION 0 SIDE CITY LIC C 8 P L I hereby affirm that I am licensed underpromions of Chapter 9 SEWER MAP (commencing with Section 7000)of Dmmn 3 of the Business and SQ FT NO OF STORIES NO OF FAMIUES Professions Code and 4wense Is in full force and effect NEW ❑ BK PG polo. d License Number LIc Class s,LC" AS DE RI, UJ K 1 \ ADD VALUATION �� Q Contractor Date �"% -93 N ALTER ❑ $ l�� (� [3 1 am exempt under Sec fV 4' `�O I�}' w Bl VI A`�-- EPAIR ❑ BBPC for this reason O 11� #IJ DEMOL 13L 23 Date USE OF EXISTING RM ❑ DMA P/C+I M.A en Signature APPLICANT(PAW) 50 TEL NO LDMA Form i 3307 .50 z— [3 ❑ 1 as owner of the probe or my employees with wages as a — 9 z 1 ITEl15 their sole compensation will do the work and the structure Is ESS not intended or offered for sale (Section 7044 Business and\ Vh O net NAL DATE C TOTAL 50.50 Professms Code) WILL THE APPLICANT OR FUTURE SULDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ❑ 1 as owner of the property am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE (N( .� licensed contractors to construct the project (Section 7044 AMO SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATIONINFORMATION GUIDE? FINAL BY > w(�{�CK Business and Professicns Code) .00 No❑ .Q0 VNLL THE INTENDED USE OF THE BUIDLIWG BY THE APPLICANT OR FUTURE BUSDMG OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST CONR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR I hereby affirm that there IDI a constriction lending agency for YES VNo❑ 1 4/30/93 a the performance of the work for which this permit Is Issued(Sec 1 p� �i/�. a IHMIEREAD THE HAZARDOUSMATERIASIFORMATIONGUIDEANDTHE SCAOMDPERMITTING 9482 1 N110:40 3097 Cw C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE IAS ANGELES COUNTY CODE C41 TITLE 2 CHAPTER 2 20 SECTIONS 2 20100 THROUGH 2 20140 CONCERNING HAZARDOUS 1 Lender's Name MATE�.�PORTIN D FOR OHTA M � SSCAQMD Lenders Addresss OR •� .* 0 I certify that I have read this i sxl and State under penalty PC FEE PERMIT FEE 3307 MOO of perjury that the above informationminformationn is correct.I agree 10 comply ' with all county ordinances and State lama relating to building 1 ITEMS construction and hereby sutlanze representatives for inspection of this County ISSUANCE FEE 2� TOTS 1�9�00 � toe upon rty for inspection purposes IA40 s • /�� m4—� INVESTIGATION FEE o So TOIIAL FEE �.7�/ MILK 179.00 SEE REVERSE FOR EXPLANATORY LANGUAGE owe .00 { r COUNTY OF LOS ANGELES TEMPLE CITY 0 05p BUILDING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SIGN BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 9906030063 PHONE (626) 285 0488 EXT r ` LEGAL 10 NUMBER OF SIGN I iw BULLDING ADDRESS 1 TR 6561 LT 344 SIGN DESCRIPTION FOAM LETTERS 5915 OAK AV TEMP CA 927802028 ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET LAS TUNAS 8587-007 008 THOMAS PAGE 596 GRID J3 LOCALITY TEMPLE CITY TENANT Urlr-M USE ISSUED ON PROCESSED BY EXPIRES ON LA BELLE FIGURE AND BEAUTY EXIST OCC GRP 06/03/99 UT 11/30/99 OWNER TEL NO BLOGS NOW ON Of VALUATION FINAL T r CODE OAK TREE SHOPPING CENTER - 350t " qC 60 CAMINO REAL AV �O I ARCD 910064043 FEES PAID NEW FOAM LETTEffB FEE DESCRIPTION QUANTITY LION AMOUNTAPPLICANT TEL NO - SAME AS OWNER - AA BLDG PERMIT ISSUANCE 27 75 AE STRONG MOTION 350 00 VAL 0 50 SPECIAL CONDITIONS 02 PERMIT W 00 VAL 43 50 PNC,ELES 71 75 CONTRACTOR TEL IW SAME AS OWNER - V� v~TY APPROVALS DATE INSPECTOR SIGNAT0ff— LIC NO LOCRT ION AND SETBACKS SOILS ENGINEEff-APPIMC- LIC 1111111 MAP NO SEWER Wr= PAGE FIRE ZONE :tgUBLIC WORKS] No 20SCHOOL WITHIN KRZMDOUS .� AIR QUALITY 1000 FEET MATERIALS NO NO NO A © ®g Service That�o< REPORT ID DPR261 ROUTE TO SS0508 COUNTY OF LOS ANGELES TEMPLE CITY 90508 BUILDING_ PERMIT ALOF BUILDING ANDNENT SAFETY /LAND DEVELOPMENT TEMPLE CITLIC WOR9701 LAS Y CSA 91780 +r' BLTONAEPAIR 05088 9906070058 PHONE (626) 285-0488 EXT LEGAL 10 No OF CONST BUILDING ADDRESS TR 6561 LT 344 SQ FT STORIES TYPE 5925 OAK AV STRUCTURE 0 VN TEMP CA 917802028 ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET LAS TUNAS 8587-007 008 THOMAS PAGE 596 GRID J3 LOCALITY TEMPLE CITY GOOD TINE LEARNING EXIST OCC GRP 06/07/99 UT 04/99 OWNER TEL NO BLDGS NOW ON Of VAL ION FINAL UTE FINAL NT r"r CODE OAK TREE SHOPPING CENTER 1 500 Ad 60 CAMINO REAL AV -12 ARCD 910064043 FEES PAID uUmmium up WORK DOOR OPENING BETWEEN 5923 AND 51WOU FEE DESCRIPTION QUANTITY UON AMOUNT APPLICANT TEL NO SAME AS OMER AA BLDG PERMIT ISSUANCE 27 75 AE STRONG MOTION 500 00 VAL 0 50 SPECIAL CONDITIONS AX BUILDING 54 70 D2 PERMIT ELE 0 VAL 143 26 45 SAPPROVALS E INSPECTOR SIONATURF-- AME AS OWNER - �.CONTRACTOR TEL NO �5 TY LIC NO LWION AND SETBACKS SOILS ENGrEWORMA7 ARCHITECT OR ENGINEER TEL NO FOUR ION/TRENCH TOW LIC NO illlill 1MAP NO SEWER NAP W= E FIRE ZONE OMER= 11180off I 5OH265 3 UBLIC WORKS FLOOR SHEATHING NO OF FAMILIES DWELLING UNITS APT/COND STAT C NO 22IF SHEATHING >V�#1l t. SHEAR PANELS AIR QUALITY 1000 FEET MATERIALS A © , NO NO NO FRAME INSPECTION REQUIRED TOTAL SETBACK FROM EXISTFIRE SPRINKLER HANGERS FEBACK YARD HWY PROP LINE WIDTHSRONT PL.- ervtce'thatINSUMION/WEATHER STRIP' - �ot SIDE PL- REPORT ID DPR261 ROUTE TO B80508 COUNTY OF LOS ANGELES TEMPLE CITY # 0506 BUILDING PERMIT f DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SIGN BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 SL 0508 9903030038 PHONE (626) 285-0488 EXT LEGRL 10 NURBER OF 5103 1 BUILDING ADDRESS TR 6561 LT 344 SIGN DESCRIPTION NEW FOAM LETTER WALL SIGN 5919 OAK AV TEMP CA 917802028 ASSESSOR INFORMATION NUMBER CROSSTUNAS 8587-007-008 HOMASTPAGEE 596RE GRID ET SJ3 LOCALITY TEMPLE CITY TENANT EXIST BLDG USE I SSMD ON PROCESSED BY EXPIRES 09 OR CHEUNG DENTAL EXIST OCC GRP 03/03/99 UT 03/03/ MINER TEL NO BLDGS NOW ON LOT VALMION FINAL DATE INAL Y OAK TREE SHOPPING CENTER - 340 / 60 CANING REAL AV I ARCD 910064043 FEES PAID IFT !r, NO FOAM LETTER WALL SIGN FEE DESCRIPTION QUANTITY UOM AMOUNT APPLICANT TEr-IW- SANE AS OWNER - AA BLDG PERMIT ISSUANCE 27 75 AE STRONG NOTI01 IE 340 00 VAL 0 50 SPECIAL CONDITIONS D2 PERMIT 00 VAL 43 75 P�GELEST 72 00 CONTRACTOR TEL NOAPPROVALS RATE INSPECTOR SIMWMT-- SAME AS OWNER LIC NO LOCATION AND SETBRCKS SOILS ENGINElff-M*ffMW ARCHITECT Olt MINEER TEL NO FOUNDATION/TRENCH FORMi LIC N 111111SUPPORT 9TRWTURE MAP NO SEWER MAP BOM PAGE FIRE ZONE XUBLIC WORKS) NO OF FAMILIES DWELLING tWITS APTIGOND STAT CLAS NO 20 .-SCHOOL WITHIN HAZAR AIR QUALITY 1000 FEET MATERIALS NO NO NO A _ y Servlc®Thst�o< REPORT ID DPR261 ROUTE TO BS050B COUNTY OF LOS ANGELES TEMPLE CITY 0 0508 BUILDING PERMIT DEPARTMENT OF PUBLIC CORKS 9701 LAS TUMAS SIGN BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 9902090016 PHONE (626) 285-0488 EXT LEGAL ID NUMBER Of SIMS I BUILDING ADDRESS TR 6561 LT 344 SIGN DESCRIPTION FORM LETTER SIGN MON ILLUMINATED 5927 OAK AV TEMP CA 917802028 ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET LAS TUNAS 8587 007 008 THOMAS PAGE 596 GRID J3 LOCALITY TEMPLE CITY TENANT lugrwm USE T93uww PROCESSED BY WIRES ON MICHELLE FASHIONS EXIST OCC GRP 02/09/99 UT 02/09/00 OWNER TEL NO SLOGS Now ON EDT VALM710M FINAL UTE FINAL BAA,'?� CODE OAK TREE SHOPPING CENTER - 150 60 CAMINO REAL AV I#.g: ARCD 910064043 FEES PAID DESCRIF H FOAM LETTER SIGN-NON ILLUMINATED FEE DESCRIPTION QUANTITY UOM AMOUNT APPLICANT TEL NO SAME AS OWNER - AA BLDG PERMIT ISSUANCE 27 75 02 PERMIT Y/0 EN- 150 00 VAL " 25 SPECIAL CONDITIONS FEES 72 00 5 P�GELESCONTRACTOR TEL NO COV APPROVALS BATE INSPECTOR SIMWMT— SAME AS DUMB V� ���► LIC NO LOCATION AND SETBACKS SOILS ENGINEER APPROVAL ARCHITECT OR ENGINEER TEL NO POLMORTION/TRENCH FORMS LIC N 111111SUPPORT STRUCTURE MAP NO SEWER W BOOK PAGE FIRE ZME BLIC WORKS NO Of FAMILIES DUELLING UNITS APT/COND STAT No 2 AIR QUALITY 1000 FEET MATERIALS l n NO NO NO g Service That��t REPORT ID DPR261 ROUTE To BS0508