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Home My Public Portal About6215 TEMPLE CITY BLVD_Building__ 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 1 have a certificate of consent to self insure, BUI DING ADDRESS or a certificate of Workers'Compensation Insurance,or a certified 11514 Lt—; el 7Y fie" VD copy thereof(Sec.3800,Lab.C.) CITY ZIP Policy No. CompanylAk LOCALITY / SIZE OF LOT NO.OF BLDGS.NOW ON LOT �L ❑ Certified copy is hereby furnished. NEAREST CROSS STV ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. depa an ASSESSOR MAP OOK P4GE PARCEL p SPECIAL CONDITIONS Date D Applicant ��5— � 6�0 CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ^ TEL O. YES NO COMPENSATION INSURANCE 1Z - fez- WITHIN 1000 FT OF SCHOOL? This section need not be completed if the permit is for one hundred ADDRESS ( P P 3 pG ,. L>. `r �,,,�� L L�� J_ L;LA5S DISTRICT GROUP TY CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) QTR w I certify that in the performance of the work for which this permit -sm 6,h014f;t_ ZIP17 is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. become subject to the Workers'Compensation Laws. �—� �h�g� S STATISTICAL CLASSIFICATION APT CONDO Date Applicant IDDRESS g�, �j� NO. DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of /'1� Lh W(sr_ �Lls P-9 rvs� � REQUIRED ' TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONT 7A^ R .� TE N _ SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith 10M` ��' FRONT comply with such provisions or this permit shall be deemed revoked. A S LIC.NO,.�j� PL LICENSED CONTRACTORS DECLARATION IT C `� SIDE CITY LIC.CL 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 sd FT.tiz NO.OF STORIES 140.OF FAMILIES Professions Code,and tic nse is in full force and effect/. '90'?/ Z NEW BK PG 0}.. License Number Lic.Class 6 DESC5JION OF WORK � ADD ❑ VALUATION ® Q Contractor Date d r'" rr-0 ALTER ❑ :-megg•DO U cc ti dS� 0 ❑ 1 am exempt under Sec. REPAIR El V BAP.C.for this reason DEMOL 11LDMA P/C# 1 w Date: USE OF EXISTING BLDG. URM ❑ /'./� n' Signature APPLI PRIN�J� EL NO. LDMA Perm# RCCTn4 co ❑ I, as owner of the property, or my employees with wages as1014rom _.iT1_G7V G o 3303 108.90 their sole compensation, will do the work and the structure is ADDRESS 1 ITEMS a not intended or offered for sale (Section 7044, Business and 11LO RIf-eq eA BSErl��F f) FFINAL DATE a Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL12-L� � TriTAL �1'6.P4�.P o � OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ 1, as owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? BY > CASH licensed contractors to construct the project (Section 7044, YES NO 108.90 Business and Professions Code.) CG� WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING .00 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT ISCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ NO 0800-0001 W the performance of the work for which this permit is issued(Sec. �}{�� 10/2J�/�5 I HAVE READ TH HAZARDOUS MATERIALS ERIALS INFORMANDE GUIDE AND THE sc S COUNTY CODE. 3003 1 Rt111�3V 3097,CIV.C.) CHECKLIST I UNDERSTA V REQUIREME UNDER THE LOS ANGELES COUNTY CODE, o CM TITLE 2,CHAPTER SECTION�,2p,0.10 HROUGH 2 20 140 CONCERNING HAZARDOUS Lender's Name MATERIALS REPO G AND,POFi G A PERMIT FROM THE 3CAOMD. IL o Lender's Address '^- O UANEP OR T o 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 �/ a with all county ordinances and State laws relating to building 4 construction, and hereby authorize representatives of this County ISSUANCE FEECD �7 to an r upon t,a above-mentioned property for inspection purpose rf 7 / J �iC��at'�— INVESTIGATION FEE TOTAL FEE I` &Walum W M a AWN �'a u SEE REVERSE FOR EXPLANATORY LANGUAGE • .V'� 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, BUI IN ADD SS 02/� G or a certificate of Workers'Compensation Insurance,or a certified 1 CITY ZIP Copy thereof(S9c.3800,Lab.C.) c�1- d LOCALITY Policy No. /! 0 Company 5 d , SIZE OF LOT I NO.OF BLDG&NOW ON LOT J�\Certified copy is here y furnished. NEAREST CROSS ST 0 Certified copy is filed with the county building inspection TACT BLOCK LOT NO. USE ZONE MAP NO. department. Date -ir/ Applicant LY' ASSESSOR M 2NO. ef �� Z` SPECIAL CONDITIONS CERTIFICATE OF EX ION FR 6RKERS' NER_ 3J� 9�'� µ TIE 7� ` WITHIN1000 FT.OF SCHOOL? YES NO COMPENSATION INSURANCE 7 (This section need not be completed if the permit is for one hundred AD REPS l,s s DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) 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 ARCHI I CT OR EN INEE TEL NO. •® become subject to the Workers'Compensation Laws. ` ,j7tel / STATISTICAL CLASSIFICATION / APT CONDO Date Applicant ADDRESS j CLASS NO. �0 DWELL UNITS f NOTICE TO APPLICANT If, after making this Certificate of 2 �/� ECUIRED TOTAL SETMQK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR yy TEL NO. SET BACK YARD HWY PROPIWE�r WIDTH Compensation provisions of the Labor Code, you must forthwith i !�! FRONT comply with such provisions or this permit shall be deemed revoked. ADDRE S LIC. r PL LICENSED CONTRACTORS DECLARATION °k 57 L G ,CL S T� SIDE CITY LIC.CLASS P L _ I hereby affirm that I am licensed underprovisions of Chapter 9A A7 EWER MAP -- (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF AMILIES >. Professions Code,and my license is in full force and effect. a NEW BK PG 0_ License Number a Lic.Class /� DESCRIPTIO OF WORK App ❑ VALUATION :-14: I;r V Contractor eagte �� 9� ALTER ❑ cc ElI am exempt under Sec. REPAIR 11 $ BAP.C.for this reason DEMO L 11LDMAPIC# -_y; i - s U -W Date: USE OF EXISTING BLDG. URM ❑ 0- Signature APPLICANT(PRINT) TEL NO. LDMA Perm# - Z ❑ 1, as owner of the property, or my employees with wages as ADDRESS p L C I n N a r their sole compensation, will do the work and the structure is FINAL D TE �-c �' not intended or offered for sale (Section 7044, Business and 3 115 L.?00- 7 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL P L-�l J +. T r��; ❑ 1, as owner of the property, am exclusive) contracting with A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 1{ ! :��!.5J Y Y g OUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY ;