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Home My Public Portal About5615 SANTA ANITA AVE_Building__ J APPLICAT16N FOR BUILDING PER IT j y COUNTY OF LOS ANGELES BUILDING AND SAFETY .` COMPENSATION DECLARATION FOR APPLICANT TO FILL IN'-WORKER'S BUILDMG ADDRESS BUILDINGCR I hereby affirm that I have a certificate of consent to self Insure, - or a certificate of Workers'Compensation Insurance,or a certified CI ZIPAl copy thereof(Sec.38010,Lab.C.) [�1nJxLOCALITY Policy No. 13-2 d Company — •/`' - ary � SIZE OF LOT NO.OF BLD 3.NOW ON LOT El Certified copy is hereby fumished. NEAREST CROSS TR El Certified copy is filed with the county building inspection �g BUSE ZONE MAP NO. dent m�a®rt. C� LOCK LOT NO. �. DateUl�Ly� ESS R MAP BOOK PAGE PARCEL pplicant 77 _402 46. SPECIAL COND IONS /D CERTIFICATE OF EXEMPTION FROM WORKERS' ffqE TEL'O. WITHIN 1000 FT OF SCHOOL? YES , COMPENSATION INSURANCE ADDR (This section need not be completed If the permit Is for one hundred DISTRICT •GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) ITv ZIP p I certify that In the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to ARCIJITECT OA-ENGINEER T No. become subject to the Workers'Compensation Laws. A WSTATISTICAL CLASSIFICATIONAPT CONDO 'MQDate Applicant A4� E� CLASS NO. �DWELLUNITt-/-- NOTICE TO APPLICANT. If, after making this Certificate of d • J9' REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject to the Workers' OR TEL.N SETBACK YARD HWY PRO .;z WIDTH Compensation provisions of the Labor Code,you must forthwith �N �c710� BACK 3499-A3 26 FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS1_30® a�� J�� n LIC.No. 3 P Y. C3 L _ LICENSED CONTRACTORS DECLARATION CITY YI 4/� LIQ CLASS SIDE _ _ 93. 8 PL V I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP 1 =r__. (commencing with Section 7000)of Division 3 of the Business and so.FT.SIZ NO.OF STORES NW FAMILIES 2. s's;a Processions Code,and y licen is in full force and NEW BK PG`! ��w+ =a •��--• � ESR ION OF ADD ❑ VALUATION , -i-+ -+ 1501 'rte W License Num T Lie.Class I _ Contractor Date 0 i ALTER ❑ $ j 1 TGM', REPAIR ❑ / ;�.. ❑ I am exempt under Sec. $ F� ��• �{., ;_jam;_ i -E c,i= .c� B.AP.C.for this reason DEMOL ❑ LDMA PIC q- •y'= Date: USE OF EXISTING BLDG. ��,Y_ � URM ❑ cal•�j-Ik ff�� l_-H tI t E r s Signature APPLICANT(PRI TEL NO. LDMA Perm g t-I �r ❑ I,as owner of the property, or my employees with wages aS62V f)4 LoorT z O their sole compensation,will do the work and the structure is ADDRESS 5 FINAL lj1=130-1 i3Ql not intended or offered for sale (Section 7044, Business and - < } rI��,! {y Professions Code.) WILLEAPPLICANTOR FUTUR UILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL Or I - y jo y S t ti I 7 e�l l ❑ I, a8 owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN a g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project.(Section 7044, YES❑ NO❑ Business and Professions Code.) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. 1 hereby affirm that there is a construction lending agency for YES❑ NO❑ the performance of the Work for Which this permit IS Issued(SBC. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD �r •" 3097,Civ.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,TITLEZ CHAPTER 220 SECTIONS 22DAWTHROUGH 220.140 CONCERNING Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. Lender's Address OWNER OR war o I certify that I have read this application and state that the above Information is correct. I agree to comply with all county Ra FEE PERMIT FEE ordinances and State laws relating to building construction,and o� J .C. hereby authorize representatives of this County to enter upon ISSUANCE FEE / the a4eykmentioned pro for Inspection pu�j (/ C�� r� INVESTIGATION FEE TOTAL FEE i/s}� // y� SpndM0fAW1=MWA9W oma V �f!!� / i SEE REVERSE FOR EXPLANATORY LANGUAGE, APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION BUILDING ADDRESS FOR APPLICA T TO PILL IN ` BUILDIN/A�RE SJ /Jy � I hereby affirm that I have a certificate of consent to self insure, �� ✓ rrOo `/v�P or a certificate of Workers'Compensation Insurance,or a certified CITY ZIP copy thereof ec„�380 Lab.C.) � ` Policy No. ��a �� Comparl�p5� `� C V GI LOCALITY SIZE OF LOT OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS . VLQertified copy is filed with the co ty buildi i spec •n TRACT BLOCK LOT NO. department. USE ZONE MAP NO. ��' Dated�� Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM OR ERS' OWNER S CoNS.T` TEL NO. YES No COMPENSATION INSURANC WITHIN 1000 FT OF SCHOOL? (This section need not be completed if the permit is for one hundred ADDRESS DISTRICT�' GROUP T E CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) CITY ZIP I certify that in the performance of the work for which this permit �o is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER become subject t0 the Workers'Compensation Laws. TEL NO. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO, DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of EFRONT TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' C TRACTOR T TEL NO. / YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith 1 I a'� �I vg— 0 41comply with such provisionsor this permit shall be deemed revoked. AD RESSS aLIC.No. � �LICENSED CONTRACTORS DECLARATION & J CITY Y„ _ ! �o _ LIC.C"C--,� I hereby affirm that I am licensed underprovisions of Chapter 9 C.�(� (commencing with Section 7000)of Division 3 of the Business and SO E NO.OF STORIES NO.OF FAMILIES SEWER MAP a O 15 Professions Code,a d m lic�eF s n full force and effe/ct. NEW BK PG v Y 1 ea -ic.ClasS c �b M,-, 2 ADD ❑ VALUATION /} 3 License Num ESCRIPT1 N OF WOR ,� O Contractor Date Z—�`2—S ALTER ❑ $ W o_ REPAIR ❑ ❑ I am exempt under Sec. $ Z_ BAP.C.for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ Signature APPLICANT(PRINT) TEL O. LDMA Perm# ❑ I,.as owner of the property, or my employees with wages as Z AC"T=� their sole compensation, will do the work and the structure is ADDRESS2 O {t, 1-6 c not intended or offered for sale (Section 7044, Business and J o �, IL FINAL DATE Q =�•�L =L f°:�'- Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 0 Z J E�I: OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ I, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 65 licensed contractors to construct the project (Section 7044, YES 11 NOL&W ~I�1 'L .. m ❑ Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING R: e OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FORGUIDELINES t� r; 1i CIO C� � t'4 I hereby affirm that there is a construction lending agency for YES❑ NO❑ 4( �� / Nthe performance Of the WOTk for which this permit IS ISSUed(SBC. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING CID 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, 7 (4 S��If I-. �? ;!�'J'•r ,-r TITLE 2.CHAPTER 2 20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS Lender's Name MATERIALS REPORTING AND'FOR OBTAINING A PERMIT FROM THE SCAOMD. . o Lender's Address �'�/ 4@48 ,f, PM 12: s IAC+ OWNER OR AGENT O ., c I certify that I have read this application and state under penalty of perjury tha4heaut nformation is correct.I agree to comply P.C.FEE PERMIT FEE N with all unas and State laws relating to building construct• n, rize representatives of this County ISSUANCE FEE mto nt ponnY ed property for inspection purposes. INVESTIGATION FEE TOTAL FEE OM SEE REVERSE FOR EXPLANATORY LANGUAGE