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Home My Public Portal About6209 TEMPLE CITY BLVD_Building__ • `�� APPLICATIC F®R BUI.LDINC PERMIT • COUNTY OF LOS ANGELS., BUILDING AND SAFETY at WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN •� , r BUILDING ADDRESS_ el I hereby affirm that I have a certificate of consent to self insure, BUILDING AD S /' or a certificate of Workers'Compensation Insurance,or a certified �� 171-1 � copy thereof(Sec.3800,Lab.C.) CITY i ZIP � �,�� LOCALITY flit c" G Policy No. Company SIZE OF L NO.OF BLDGS.NOW ON LOT dGL Certified copy is hereb furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the county buil ' g inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. �'��' Applicant moi✓ 6/ ASSESSOR MAP OOK PAGE PARCEL Date pp� � �� SPECIAL CONDITIONS CERTIFICATE OF EXEM��,l N FF� M RKERS' OW ER 000 TEL NO. meg/ COMPENSATI INSUKAN /'' -oC p l9 Q �� l0 WITHIN 1000 FT.OF SCHOOL? YES �_ NO ADDRESS y (This section need not be completed if the permit is for one hundred 0 (+ �• l , �j�� tl DISTRICT GROUP TYPE CONST. FIRE•ZONE- PROCESSED BY dollars($100)or less.) -.3 6 1, -— . CIT 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 RC T 0 p/ /C become subject to the Workers'Compensation Laws. ACT OR ENGI EER EL NO.• o. �O/ STATISTICAL CLASSIFICATION APT__ CONDO 7 O CLASS NO. �a DWELL UNITS Date Applicant ADD ESS � ••- ,• _ NOTICE TO APPLICANT.• If, after making this Certificate of Y �� EOUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. ET BACK YARD HWY PROP WIDTH Compensation provisions of the Labor Code, you must forthwith - AI C FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS _ LIC.NO. �+� PL LICENSED CONTRACTORS DECLARATION C s A) sG �8 SIDE cl LIC.c s P L I hereby affirm that I am licensed underprovisions of Chapter 9 r�- 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 m_y license is in full force and effect. „1[7 NEW BK PG ® d ! OF WORK ADD ❑ VALUATION Q License Number Lic.Class 0 DESCRIPTIO Contract 6 C= pate L /� �,d J ALTER ❑ $ ® B� V ❑ I am exempt under Sec. REPAIR El $ BAP.C.for this reason DEMOL ❑ LDMA P/C# V W Date: USE OF EXISTING BLDG. URM ❑ a CO Signature APPLICANT(PRINT) TEL NO. LDMA Perm# - z ❑ I, as owner of the property, or my employees with wages as ZO ,�:t T. their sole compensation, will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and FINAL DATE Q `�0 LQf 9. •`.! Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL "'-`'" R A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR-GREATER THAN THE ��~ -J '�f ENS, ❑ I, 8S owner of the property, am exclusively contracting with OUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project (Section 7044, �� A TOTAL x,879,95 YES 11 NO❑ �wM " Business and Professions Code.) r .� WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING l.�-tr;_l.l1 1879.95 OCCUPANT REOU:RE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR �^ CHANGE 0 1U /A I hereby affirm that there is a construction lending agency for GUIDELINES V YES El No ElI�Iyl Nthe performance Of the Work for which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING I W3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. 1 ! 0 rF 0 7 155/15/95• C C' a TITLE 2,CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS =i�Ji.li.7`t.E�LI J. _I,I j.J j'�j'.�! Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. C t 0 Lender's Address 1-`' '� �' tI[°I113 336 pyVER OR AGENT O c I certify that I have read this application and state under penalty P.C.FEE PERMIT FEE 4 of perjury that the above information is correct.I agree to comply ow • /U N with all county ordinances and State laws relating to building O construction, and here auth oze rep entatives of this County ISSUANCE FEE to enter upon the 6 Mme ti6ned pro ty for'nspection purposes. 01 ,/ �i/S• �S INVESTIGATION FEE TOTAL FEE J �. Sq�WYN W APC full IX N DHY SEE REVERSE FOR EXPLANATORY LANGUAGE I APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDI r_ADDRF.Rq [BUIL ING ADD ESSI hereby affirm that I have a certificate of consent to self insure, C�'�!' 0�Vor a certificate of Workers'Compensation Insurance,or a certifiedY,._ ZIP 1 copy thereof(Sec.3800,Lab.C.) • xm� ,ey� L G LOCALITY Policy No. Comperry SIZE OF LOT NO.OF BLDGS.NOW ON LOT 73L V ❑ Certified copy is hereby furnished. I NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. Date Applicant ASSESSOR MAP 00 PAGE PARCEL \ ��I� Q�� dp 17 SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ^ TEL NO. COMPENSATION INSURANCE EC QEve Lo )N C� 6 '5366 WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADD ss ,y O C✓. ly�.�g�� Ly dollars($100)or less.) P E DISTRICT GROUP Ty.99 CONST. FIRE ZONE PROCESSED BY I certify that in the performance of the work for which this permit CITY_ J-��e7L_ � ZIP 1776 is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER L NO. f l/ become subject to the Workers'Compensation Laws. _el#o S �/�ry�0� STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS n,, nL CLASS NO. DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of / 1-0PJIJ� 5 L��% 0JM6AQ REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject t0 the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith —0-17-15 FRONT comply with such provisions or this permit shall be deemed revoked. ADD SSLIC 0. P L LICENSED CONTRACTORS DECLARATION �d 4-`f 7.3 SIDE ClT /J_ _ / UGss 4, PL I hereby affirm that I am licensed underprovisions of Chapter 9 ��-`�•-+v �Ge%v6G.� SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO.FT.SI NO.OF STORIES I NO.OF FAMILIES Professions Code,-a d my licen a is in full force and effect. 1Z 11 / Z NEW 9 BK PG ® a License Number � _ Lic.Class L DESCRIPTION OF WORK ADD ❑ VALUATION Q Contractor s &C121�i� Date S 2/,s��'Lf /�O�Z $ `Odd'IP01 0 L^ ALTER ❑ ElI am exempt under Sec. S/ L REPAIR ❑ Q B.BP.C.for this reason DEMOL ElLDMA PTC# W Date: USE OF EXISTING BLDG. URM ❑ IL Signature APPLICA PRINT y-• L `` LDMA Perm#� G ❑ I, as owner of the property, or my employees with wages as fl �� /14 f�1b7 O G Z ACCT.0 their sole compensation, will do the work and the structure is ADDR SS p O not intended or offered for sale (Section 7044, Business and 1 (orJ� I SA APAP D S EMGL17 FINAL DATE Q 3303 103.90 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 1 ITEMS ❑ I, a3 owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? licensed Contractors t0 construct the project (Section 7044, FINAL BY ' TOTAL �� r a 90Business and Professions Cade.) YES 11No WILL THE INTE DED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING CHECK 101.90 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH .�• �� CONSTRUCTION LENDING AGENCY GOOSE AIR NES QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR hL�/� /-r erypy I hereby affirm that there is a construction lending agency for YES❑ NO .� CHANGE v�J athe performance of the work for which this permit is issued(Sec. 0IHAVE READ THE 4ZARDOUS MATERIA INFORMATION GUIDE AND THE PERMITTING ODE. J ��—�� 10/ /9 3097,CIV.C.) CHECKLIST I UNDERSTAND M RE EMENTS UNDER LOS ANGELES COUNTY CODE, Q/�/• 5 CM TITLE 2,CHAPTER 2 20 SEC 2 20.10 G 20 140 CONCERNING HAZARDOUS Y� (�, Lender's Name MATERIALS REPORTING A R OBTAI G FROM THE SCAOMD. Lender's Address �� 3006 1 AN 110 39 O p,YNER OR AGENT c I certify that I have read this application and state under penalty 0 of perjury that the above information is correct.I agree to comply P.C.FEE e7V / 3 PERMIT FEE 0 CM with all county ordinances and State laws relating to building �• construction, and hereby authorize representatives of this County ISSUANCE FEE O tp enter upo the above-mentioned property for inspection purposes. a roA INVESTIGATION FEE TOTAL FEE / n1• SEE REVERSE FOR EXPLANATORY LANGUAGE