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Home My Public Portal About6213 TEMPLE CITY BLVD_Building__ ~`= : APPLICATION FOR BUILDING PERMIT LJ • i COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDI G ADDRE S I hereby affirm that I have a certificate of consent to self insure, BUI DING ADDREqSS%/J� �� or a certificate of Workers'Compensation Insurance,or a certified �� `� copy thereof(Sec.3800,Lab.C.) CITY zIP S,/af fj . el-e s 17 v LOCALITY Policy NO� Company SIZE OF L NO.OF BLDGS.NOW ON LOT G CSG Certified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. Date�[�. Appli�ant ASSESSO MAP OOK PAGE PARCEL p ,, Oae o SPECIAL CONDITIONS CERTIFICATE OF EXEM ON FROM WORKERS' OW ER j TEL NO. COMPENSAT INSURANCE 'o/ c. �� 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.) n J a>r Q '•/ 1� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY I certify that in the performance of the work for which this permit CddN adkp ZIP f17ZI-;- �� is issued, I shall not employ any person in any manner so as to A TELT ORE IN R TEL NO. Z�¢ become subject to the Workers'Compensation Laws. r—ZIARu -0fe%� STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS � n ".212O r 7 CLASS NO. " DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate of i l'lr e4,fir Y Y7t 7 REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO SET BACK YARD HWY PROt?LINE WIDTH Compensation provisions of the Labor Code, you must forthwith _ izz.,/we l�a� z��3�� FRONT �- comply with such provisions or this permit shall be deemed revoked. ADDREP LIC,NO. PL IMI 3 LICENSED CONTRACTORS DECLARATION 3� 5. -L SIDE _ CIT LIC.CLASS PL_ �'T_-_+• j`' i I hereby affirm that I am licensed underprovisions of Chapter 9 .. (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES _ WER MAP 1 i Professions Code,and my license is in full force and effect. -2D Z NEW BK PG ® } License Number Lic.Class DESCRIPTION OF WOR ADD ❑ VALUATION ContractorAl Is �-�/'�- �' ALTER ❑ $ cc REPAIR ❑ ` ''3� 0 ❑ I am exempt under Sec. $ F- UBAP.C.for this reason DEMOL 11I LDMA P/C# USE OF EXISTING BLDG. '1 I' ~ '- Date: URM 11 _jl_I�__)_IJ __: Signature tD LICANT(PR/NT) TEL NO. LDMA Perm# i�i_7 _ F t -r _Z ❑ I, as owner of the property, or my employees with wages as Z their sole compensation, will do the work and the structure isRESS O not intended or offered for sale (Section 7044, Business and FINAL DATE a .. Professions Code.) LL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL G q�. 'r A A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE VJ 5_Ci e7 ❑ I, as owner of the property, am exclusively contracting WlthOUNTS SPECIFIED ON THE HAZARDOUS MATERULLS INFORMATION GUIDES licensed contractors to construct the project (Section 7044, FINAL BY -3('� 86cS❑ NO❑ s_'Jv `L�'Business and Professions Code.) L THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BU.LDING "TEN CURANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 1 i Ct:J CONSTRUCTION LENDING AGENCY AST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR _ 1 hereby affirm that there is a construction lending agency for YES❑NES NO❑ /110 rl i � 1865.79 W the performance of the Work for Which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMA71ON GUIDE AND THE SCAQMD PERMITTING CHECK bti'��=7�0 � T 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,cm 'I�P)_ e TITLE 2,CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20.140 CONCERNING HAZARDOUS 1;�J A 41 V Lender's Name MATERIALS REPORTING AND FOR OBTAIN!NG A PERMIT FROM THE SCAOMD Lender's Address C OWNER OR AGENT c I certify that I have read this application and state under penalty �(� _ �, `/15/95 of perjury that the above information is correct.I agree to comply P.C.FEE f! PERMIT FEE / p N with all count ordinances and State laws relating to building �` e • /�� f =i y 9 9 .37091 _ i'l. }.0 mconstruction,and h y author representatives of this County ISSUANCE FEE -q/, J7,co to enter upon t ' n ove-me ed perty for inspection purposes. m `/y � _4- TOTAL FE INVESTIGATION FEE (i`/ £g.Iwu of App' ARnI 0.w Q (O 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 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 &Z11'15 J(:RM LG 61-TY �(.d D 67 copy thereof(Sec.3800,Lab.C.) Policy No. Company CITY I Es `� GI T IP LOCALITY SIZE OF LOT_1 NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS Tr. ❑ Certified copy is filed with the county building inspection TRACT BLACK LOT NO. dep�en USE ZONE MAP NO. DatePPlicant ASSESSOR��BOr PAGE PARCEL ��'� 0// Be9 SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER _ TEL NO. COMPENSATION INSURANCE R- IEU WITHIN 1000 FT.OF SCHOOL? YES No (This section need not be completed if the permit is for one hundred ADDRESS 3O/- C] ��gw�L PJ Lv� "M DISTRICT GROUP TY CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) W I certify that in the performance of the work for which this permit CITY ZIP1776 n� �2 is issued, I shall not employ any person in any manner so as to �u —�J ARCHITECT OR ENGINEER become subject to the Workers'Compensation Laws. TEL NO. TSH A$,sIpC1/a-f 65 P4 MIS)¢41-670 G STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS q 1� CLASS NO. DWELL UNITS NOTICE TO APPLICANT.• If, after making this Certificate of )13 e-D w 6 Aeq SA ��! SUh4'C_ l7 REQUIREDTOTAL SETBACK FROM EXIST Exemption, you Should become Subject to the Workers' CONTRACTOR 'L No, SET BACK YARD •HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith /v FRONT comply with such provisions or this permit shall be deemed revoked. AD RES D �� UC. O. PL LICENSED CONTRACTORS DECLARATION SIDE CITY � LICCLAS� PL I hereby affirm that I am licensed underprovisions of Chapter 9 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 Slice is in full force and effect. `ZlJ�� 2- f NEW � BK PG ® }a License'ns Lic.Class DESCRIPTION OF WORK ADD E] VALUATION /o ._y�`4 s 1N&eL/Z el Si,L I $ Z OO•oO Contractor Date I� ALTER 11 ElI am exempt under Sec. " mss REPAIR ❑ $ Q BAP.C.for this reason DEMOL ❑ LDMA P/C# USE OF EXISTING BLDG. i�`GT°4 Date: URM ❑ tlt4 � Signature AP ICANT(PRIINT) ELN A LDMA Perm# Z ❑ I, as owner of the property, or m employees with wa es as �OH °17 /$ 7 C Z vs their sole compensation, will do the work and the structure is ADDRESS 0 330310 03 +�0°90 not intended or offered for sale (Section 7044, Business and /n tower 41116.4 fP-If&_P FINAL DATE / � Professions Code.) ry�,h. �q( 0 1 ITEM MALL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL (� lrC. 1 i IR OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE TOTAL �.� '` '� ❑ I, as owner of the property, am exclusively contracting With AMOUNTS SPE�ICIFIEEp ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project (Section 7044, YES❑ NO/LT` 10& 90 Business and Professions Code.) CHECK ° WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING °�� OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH /J �[, ,1( �� hL1A �E CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR [/Q/ C• f CHANGE GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ NOX r7 /Q W the performance Of the Work for which this permit IS ISSUBd(SBC. 1 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING pOQO-0001 10!/75/ /C 1 3097,CIV.C.) CHECKLIST I UNDERSTA MY REOUIREMEN UNDER THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPT 2 SECTI 0 HROUGH 2 20.140 CONCERNING HAZARDOUS �7 - 3Dpy. i 011"S39 Lender's Name MATERIALS RE JJG AND OR Q G A PERMIT FROM THE SCAOMD. o Lender's Address O OWNER 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 Xr 6 C N with all county ordinances and State laws relating to building 'J CO construction, and hereby authorize representatives of this County ISSUANCE FEE 3� ato enter upon the above-mentioned property for inspect' n purr o as C� co C� INVESTIGATION FEE TOTAL FEE Sg� !Ap •nl m ASMilll" SEE REVERSE FOR EXPLANATORY LANGUAGE