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Home My Public Portal About5617 SANTA ANITA AVE_Building__ WORKERS' COMPENSATION DECLARATION • insure, or•a certif catte of Workers' Compensat on InsurancI have a certificate'of coent to e, APPLICATION FOR "U I L D I N G PERMIT or a certified d cop��y7t there/of (Sec. 3800, Lab.9C vb�� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.3 1V 06tompany— ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDR1EN,SGS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS DateL `v`93riffDtj;� �L�1� CITY ZIP LOCALITY NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION.FROM WORKERS' SIZE F L NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR ��ff (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK ' PAGE v� PARCEL hundred dollars ($100)or less.) �T, •. ti. r•,TEL. OWAIER USE ZONE MAP I certify that in the performance of the work for which thisNO. SPECIAL >_ permit is issued, I shall not employ any person in any manner ADDRESS . . le-9 CONDITIODdi a so as to become subject to the Workers'Compensation Laws. Q CITY Zip Date Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER N DISTRICT GROUP TYPE FIRE PROCESSED BY Q Exemption, you should become subject to the Workers' CONS,T./ ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS �� A2-3 with comply with such provisions or this permit shall be f TE STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR 1et T r N v(J� Z LICENSED CONTRACTORS DECLARATION [� CLASS NO. awe DWELL. UNITS�� ADDRESS/3490 /�N1 'fTl'�� I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP ' (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Co e,and m license is in full force and effect. CITY CLASS BK PG �L:. VALIDATION 2 SQ. NO. OF NO. OF CHECK 1. Lice se Nu Fer6df3 Lic. Class 46 SIZE TO5[ES FAMILIES ONE I::;t;; =T VALUATION Co frac ,b}e /7 DESCRIPTION OF WOR r NEW Vii_'' �•=._, C +�CPd•'✓ - �C!�� ADD ❑ - ❑l am p u er Sec. ► - ALTER A0 _ B.BP.C. for this reason REPAIR ; ��/' -• ---'7 ❑ USE OF Date: EXISTING BLDG. 14 DEMOL ❑ -- - - Signature APPLICANT TEL FINAL ;ii'' '_ +'i-1- OWNER-BUILDER DECLARATION (PRINT) NO DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS 14 FINAL Professions Code): PRESENT By ❑ I, as owner of the property,. or my employees with AD KESS ' i ��''_'�,_ `- wa es as their'sole compensation,will do the work and ! O 9 P LOCALITY n 3303 ��i 1. l 1 the structure is not intended or offered for sale(Section U ,`I' • 7044, Business and Professions Code.) MOVING TEL. JrZ TENS E] 1, NO.I,as owner of the property,am exclusively contracting ��- r ._. �O; with licensed contractors to construct the project (Sec- ,/� ( (11- -'- '.61 tion 7044, Business and Professions Code. ADDRESS CHECK �y . REQUIRED TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH f-Y I hereby affirm that there is a construction lending agency for FRONT C i�AN"GE •00 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. 1.:000-0001 9/1-0/93 Lender's Name pC �/ W ` LDMA Ref.# $ P.C. Fee$ • Permit Fee J� 61,5 $=rel Lender's Address f I certify that I have read this application and state that the �a • �r Issuance Fee LDMA P/C# Poo 3 above information is correct. I agree to comply with all County Investi ation Fee !!�� .( ordinances and State laws relating to building construction, Total Fee t� o 10 LDMA Perm. # and hereby authorize representatives of this County to enter upon t bove-mentioned operty for inspection purposes. apA �. `�3 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date - APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY -WORKER'S COMPENSATION DECLARATION FOR APPLICAN TO FILL IN BUI IN ADORES I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS vg � / or a certificate of Workers'Compensation Insurance,or a certified 1'19 copy thereof Sec.3800,Lab.C.) r� CITY (/,1f ZIP Policy No. , ' Compan &A+ � �• — " LOCALIT SIZE OF LOT M.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. &-Certified copy is filed with the c my build! sp ion TRACT BLOCK LOT NO. departm-••�ent. USE ZONE MAP NO. Date -ZZpplicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WO ERS' OW ERR j /� ( TEL NO. COMPENSATION INSURAN E ,/64 C r i � . � � Z WITHIN 1000 FT OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS dollars($100)or less.) I'vi S DISTRICT GROUP E CONST. FIRE ZONE PROCESSED BY CITYe kms_ ZIP I certify that in the performance of the work for which this permit L is issued, I shall not employ any person in any manner so as to become subject t0 the Workers'Compensation Laws. ARCHITECT OR ENGINEER EL NO. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE 70 APPLICANT.• If, after making this Certificate of REQUIRED' TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CTO w ` TEL NO.��1 ` i SET BACK YARD HWY PROP LINE WIDTH fp Compensation provisions of the Labor Code, you must forthwith —96 +7I� - S l�"'«�"ly) FRONT comply with such provisions or this permit shall be deemed revoked. AQDSS e LIC.NO. ,j t PL LICENSED CONTRACTORS DECLARATION t `� SIDE _, CRY Y' `� LIC.CLASt�� PL f_; 1 hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP - (commencing with Section 7000)of Division 3 of the Business and SQ.FTS NO.OF SS ORIES NO.OF F MILIES 3 } / {'�7�-' n Tr a Professions Code,and my license is in full force and effect. NEW -W BK PG `{ _ cCy, 00- 3.61.3 121 License Number 1�� Lic.Class �'�� ESCRIPTI OF�j°RK ( ADD ❑ VALUATION � I� •'' � `\ S Rl�itZS ❑ Contractor Date Z '2 Z. — -`/'�/ ALTER $ XT f EM REPAIR ❑ s`�3 - i 50 a ❑ 1 am exempt under Sec. $ �) '�� '� E 6 r/ B.&P.C.for this reason DEMOL [I LDMA =16°N3� LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ f,HA''GE °DO Signature APPLICANT(PRINT) qtq TE /I LDMA Perm# ryftiC i IL ❑ 1,.as owner of the property, or my employees with wa es as �1 6_ Z their sole compensation, will do the work.and the structure is ADDRESS O �II 1-f]im 1 s-t"'� 6871.t not intended or offered for sale (Section 7044, Business and �� FINAL DATE' C a `3 + a• :; Professions Code.) _r960 ITEI Ar.14 2 WILL THE APPLICANT OR FUTURE B ILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL -p �• ❑ 1, as owner of theproperty, am exclusive) contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE FINAL BY V�� > I( E YL .5.+1=d o y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? 8-5 licensed contractors to construct the project (Section 7044, yes 11 No❑ �`: iE�a t�l Business and Professions Code.) WILL THE INTENDED USE'OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING f OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CHAT GE a 1 0 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ NO❑ •� �•1 a the performance Of the Work for which this permit IS ISSUed(SBC. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING I100I0^L't�i`01 2/ 22.194 3087,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, _ CV TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2:20.140 CONCERNING HAZARDOUS �• w Tr° IL i Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. '7 CI � + f"1 1°0'" o Lender's Address G OWNER OR AGENT c I certify that I have read this application and state under penalty 4 of perjury that the abo formation!s correct.I agree to comply P.C.FEE /y� / ,�y, PERMIT FEE N with all c unty Ord ina ce and State laws relating to building O[ /� V cc stru n,and hereb tho a representatives of this County IPSUANCE FEE �L CO to upon th ove ntlo property for inspection purposes. i T C ✓A _5 Y INVESTIGATION FEE TOTAL FEE CD fimnt or ApMI Dere r • J SEE REVERSE FOR EXPLANATORY LANGUAGE ' - ',• ,_ ` Gt� APPLICATION FQR BUILDING PERMIT. c�3 COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN ' BUILDINF ADDRESS `I hereby affirm that I have a certificate of consent to self insure, BUILDIN AD``D_RESSC 17 S6rL. C/�%lG sir or a certificate of Workers'Compensation Insurance,or a certified `��/ T01�N/�� ' copy there f(Sec.38p� b.C.) _�. '�,_� CITY � wD66 ^,` ZIP ^n // `•�f{/ cam", "[ �f LOCALR Policy N Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT C r ❑ Certified copy is hereby furnished. . / � NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT n q D BLOCK J] LOT NO. vu de artmeent. ,� lag,? `/ 6D USE ZONE MAP NO. Date -`�vplicant 'De" C ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER .�,I * 0N�wa T L2D8,182$ COMPENSATION INSURANCE �"1 WITHIN 1000 FT.OF SCHOOL? Yes No . (This section need not be completed if the permit is for one hundred ADDRESS/�DO &AI a/ 've DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) WQ CITY ZIP 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 ARCHITECT OR ENGINEF�, TEL O. O # become subject to the Workers'Compensation Laws. J�� C O �� STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS le 96 j G ��t/ CLASS NO. DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate of �V �y� REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject t0 the Workers' � NO. SET BACK YARD HWY PROP LINE WIDTH CO Compensation provisions of the Labor Code, you must forthwith r { 6 . FRONT comply with such provisions or this permit shall be deemed revoked. _- a_1VS j � LIC.No. P ` PL LICENSED CONTRACTORS DECLARATION [ / fj SIDE. C Ap9— /►� Aa/ LIC.CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 J�� C.. /t!J(j/ SEWER MAP (commencing with Section 7000)of Division 3 of the Business and POJk9IZE NO.OF STORIES NO.OF FAMILIES Professions CodWyl full force and eCt. z NEW ❑ BK PG a 4 DESCRIPTION OF WORK VALUATIONLicense N rIc.Clas ADD ❑ e7OContractoatey6� - 7 ALTER ❑ $ teeliel "Lank 1itt}GL- C ❑ REPAIR 11I am exempt under Sec. � U/V $ .�� BAP.C.for this reason AVA '9 1`� DEMOL El P/C# Ij Date: USE OF EXISTING BLDG. URM ❑ - a Signature APPLICANT(PRINT) TEL NO. LDMA Perm# z ❑ I, as owner of the property, or my employees with wages as Z their sole compensation, will do the work and the structure is ADDRESS O f Ss'- - a_� FINAL DATE ~ 330 not intended or offered for sale (Section 7044, Business and � Q _ pas owner of the rofessions Code.) I WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT'HANDLE A HAZARDOUS MATERIAL ` 1 k E 1_f NJ I, OR 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? Q IF a —q r'-it- C' licensed contractors t0 construct the project (Section 7044, FINAL BY > TOTAL Lu �2__ Business and Professions Code.) YES El No Ellr WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING ':i�Et:�•i �+:'i a i•. OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FORt,es` Jff GUIDELINES e_� I hereby affirm that there is a construction lending agency for YES❑ NO❑ C4 the performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING j i fi-•ec- N 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, 1313-11313-00113 ' — TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS t Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. IL Lender's Address OWNER OR AGENT c I certify that I have read this application and state under penalty of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE /1/ r/ N with all county ordinances and State laws relating to building // d g construction, and hereby buthorize representatives of this County ISSUANCE FEE / "' to ente the above meet�'ape��propert for inspec'on u os�q 4• CO `4 C��LZP,t�t-y o j. 7 10 ! INVESTIGATION FEE TOTAL FEE /& 3/ I ^ Mq ture of AMD—n Ar-M Date I SEE REVERSE FOR EXPLANATORY LANGUAGE