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Home My Public Portal About6211 TEMPLE CITY BLVD_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUI INNG�ADDRESS B ILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, Z �M Lc G� DL V or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) "'I ZIP SNP Z� e--)TY LOCALITY Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT G ❑ Certified copy is hereby furnished. ____ I NEAREST CROSS ❑ Certified copy is filed with the county building inspection TRACT LOT NO. department. !/ USE ZONE MAP NO. Datel��Applicant ASSESSTA PAGE PARCEL� O SPECIAL CONDITIONS CERTIFICATE ON INSURANCE 14A:)-- O1A:)- Tex- i�e�c-C.o"PA TEL 8/$NO. 2 '7�'i3� Yes No WITHIN 1000 FT OF SCHOOL? ADDRESS (This section need not be completed if the permit is for one hundred` / EJB /°�g�,�L L�f DISTRICT GROUP E CONST FIRE ZONE PROCESSED BY dollars($100)or less.) (� l C97 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 ENGINEER�`�� L �NO / �� _ G become subject to the Workers'Compensation Laws. O�1 �� y�Gf�� y �J_,lI STATISTICAL CLASSIFICATION APT CONDO Date Applicant A DRESSSr G p, J�f7�7 n CLASS NO. DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate Of 11-L,/ L97 W V P— �"�ee,A r �j j&WE,4% REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' ONT ACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith C_ 4!2A9C) FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS ail LIC.NO. PL LICENSED CONTRACTORS DECLARATION h SIDE CITY LIC.CLAy�S PL I hereby affirm that I am licensed underprovisions of Chapter 9 G SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT IZE NO.OF STORIES I NO.OF AMILIES1 Professions Code,and li en is in full force and eff t. '2 d Z f NEW ,ra• BK PG ® } + License Number LIC.Class J1& DESCRIPTION OF WORK ADD ❑ VALUATION 9' Contractor Date�d— T Et2 2 ALTER El � �� ' C El REPAIR ElI am exempt under Sec. $ BAIL for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ 1 d ACCT. Signature APPL NT rpmo L( TEL N FFINAL Perm# r ❑ I, as owner of the property, or my employees with wages as 0!� CO HT1 704 Z their sole compensation, will do the work and the structure is ADD SS O_ t5e9_ not intended or offered for sale (Section 7044, Business and L�u Its S� ��j � DATEProfessions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ❑ 1, as owner of the property, am exclusively contracting With OR A MIXTURE CONDONING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE a �{� u AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY 0 3130L � '`M I I o licensed contractors to construct the project (Section 7044, 39 Business and Professions Code.) ves 11 No NW WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ No� c., the performance of the work for which this permit is issued(Sec. \rn I HAVE READ TH HAZARDOUS RIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,CIV.C.) CHECKLIST I UNDERSTA QUIREME 7S UNDER THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 26N R GH 2 20.140 CONCERNING HAZARDOUS 3 Lender's Name MATERIALS REPORTI D FOR G RMIT FROM THE SCAQMD. o Lender's Address C OWNER OR AGE c I certify that I have read this application and state under penalty C of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE j 6� N with all county ordinances and State laws relating to building CO construction, and hereby authorize representatives of this County ISSUANCE FEE y 1O ato a ter upon the bove-mentioned property for ins act i n purpose . / b INVESTIGATION FEE TOTAL FEE J) y p SgNluro W b,t a ApData (/ 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 BUIL DINS,ARDRESS I hereby affirm that I have a certificate of consent to self insure, BUI/L�gING ADD ESS or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) �r�1 CITY- z / ZIP � Policy No. 3 Company' • �� ` "� ' L r NO LOC AUT SIZE OF T NO.OF BLDGS.NOW ON LOT XCertified copy is he by furnished. NEAREST CROS ST. El Certified copy is filed with the county building inspection TRACT BLOCK LOT No. department. USE ZONE MAP NO. Date ��JS pplicant+ ASSESSOR MAP BOOK PAGE PARCEL � r� �5 Q�� 6� SPECIAL CONDITIONS CERTIFICATE OF EXEMP FR WOK OWNER //�J TEL NO 2 COMPENSAT INSURANCE r — a ¢ Alt � /� WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS ` e� . o S' � r • / � DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) CIT I certify that in the performance of the work for which this permit ZIP a + is issued, I shall not employ any person in any manner so as to ARCHITECT OR"GINE' TEL NO. _3 become subject to the Workers'Compensation Laws. , C N / p J D� STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS O �p C CLASS NO. 19P40 DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of 5Utz .¢%' ' TIa rF EOUIRED TOTAL SETB/�tj FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. ET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith - r - 10f- " NT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. - Ssj 7 vd -- 0 � E "'"LICENSED CONTRACTORS DECLARATIONLIc.cLAss I hereby affirm that I am licensed underprovisions of Chapter 9 y SEWER MAP _ (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE No,OF STORIES NO.OF FAMILIES Professions Code,and my license is in furl force and effectV. . .�D NEW BK PG 'M'- � - DESCRIPTION OF K App ❑ VALUATION = �. License Number c.Class ®�+ �l.>� B-O Contractor L ALTER ❑ $ /��.7 �� •"iii 11 U —� �.-M ❑ 1 am exempt under Sec. REPAIR ❑ $ C BAP.C.for this reason DEMOL 11LDMA P/C# �" '� -- —1 A—'t r W Date: \ USE OF EXISTING BLDG. URM ❑ `'{ i _ + Signature ; + 'y+ z APPLICANT(PRINT) TEL NO. LDMA Perm# ❑ I, as owner of the property, or my employees with wages as V O j their sole compensation, will do the work and the structure is 1 ADDRESS not intended or offered for sale (Section 7044, Business and FINAL DATE a �•r•^r .0 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ,I�Z•�� 1:1TAI 1, as owner of the property, am exclusively contracting With OR A MIXTURE CONNING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q ,;I.'.}03 1865.79 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES licensed contractors to construct the project (Section 7044, FINAL BY � > TT-VES❑ NO[IA I L"N-,z L Business and Professions Code.) LL �] THE APPLICANT OR FUTURE OCCUPANTINTENDED REQUIRE A PWLL THE ERMIT FOR CONSTRUOF THE BUIDUNG CTION OR MODIFICATION FROM THEUILDING SOUTH Y (_ COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKUST FOR I I�Iv/ TOT I CONSTRUCTION LENDING AGENCY GUIDELINES _.'-(FIX 12-6-5.97I hereby affirm that there is a construction lending agency for � VES El NO❑ n the performance of the work for which this permit is issued(Sec. ® I A11t3�If (0 1 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING E _--1-- 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, ITLE 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. 0 Lender's Address ';00-11 0 E f15/9r O INNER OR AGENT o I certify that I have read this application and state under penaltyI' o P.G IFEE y PERMIT FEE /�� 133913 y f 110 ''- d of perjury that the above Information is correct.I agree to comply OY C4 with all county ordinances and State laws relating to building construction, and,00reby author zefepresentatives of this County ISSUANCE FEE M to enter upo bo Ion tD arty for inspection purposes. (o d CD f�-JS INVESTIGATION FEE TOTAL FEVS ` �(' del Sg,=iwo al App' r Apem 0.:.o CO ✓� SEE REVERSE FOR EXPLANATORY LANGUAGE