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Home My Public Portal About6449 LOMA AVE_Building__ WORKERS'COMPENSATION DECLARATION 850622 TC hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) �V85-225154 Fremont indemnity COUNTY OF LOS ANGELES BUILDING AND AFETY Policy ompany Y BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING --_— tion department. ADDRESS 6449 Loma Ave. LOCALITY 1 1/27/85 Virgin Roof CO NEAREST Date Applicant g CITY Temple City ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP hundred dollars $100 or less. TRACT BLOCK LOT NO. NO. dollars ($100) ) TEL. SPECIAL that in the performance of the work for which this OWNER Fred Leben NO. CONDITIONS I certify P DISTRICT GROUP TYPE FIRE PR ESSED BY 0 permit is issued, I shall not employ any personinany manner 6449 Loma Ave v.� CONST. j ZONE U so as to become subject to the Workers'Compensation Laws. ADDRESS V e - CITY Temple City ZIP STATISTICAL CLASSIFICATION APT. OONDO. Date Applicant ARCHITECT OR TEL. U NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CLASS NO. &V _DWELL. UNITS LU Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER P with comply with such provisions or this permit shall be TEL. deemed revoked. CONTRACTOR Virgin Roof CO NO. 287-05 BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. ]60650 I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESSp 0 BO J NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY San Gabriel CLASS C39 $ 560.00 , SQ. FT. NO. OF NO.OF CHECK License Number 160650 Lic.Class SIZE SIZE STORIES 1 FAMILIES ONE ControctoYlrgiri Roof Co pate] 1/27/85 DESCRIPTION OF WORK Tear Off exist. NEW ❑ $ roofs and re-roof with #30, ADD ❑ z2 3 6 S 1 A ❑ 1 am exempt under Sec. # 15 and #72. Flat roof only ALTER E] FINAL �� o 0 0 0 0 B.&P.C. for this reason REPAIR ❑ 1 Date: USE OF 2 squares. DEMOL ❑ B NAL 1 0 o33,00 EXISTING BLDG. Signature APPLICANT TEL. Y , ' 0 003a003': OWNER-BUILDER DECLARATION PRINT Virgin Roof CO NO. 287-0507 I hereby affirm that I am exempt from the Contractor's License ADDRESS P O BOX J, San Gabr ie 1 91778 , 1 212-85 Law for the following reason (Section 7031.5, Business and ) I Professions Code): PRESENT ❑ BUILDING LL I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIREDTOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY —SET BACK YARD HWY PROP. LINE WIDTH , I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). rInvestigation m Lender's Name Lender's Address Permit Fee 22.50 I certify that I have read this application and state that theIssuance Fee 10.50 above information is correct. I agree to comply with.all County 33�0� Msi nd State laws relating to building construction, Total Fee u uthorize representative of this County to enter m ve-mentioned perty or inspection p rposes. l� v SEE REVERSE FOR EXPLANATORY LANGUAGE re of App icant or Ag nt Date ®a DSS-3 25M SETS 2.46 DEPAR!PM2NT OF BUILDING AND SAFETY -APPLICATION FOR PERMIT ` COUNTY OF LOS ANGELES Vv PA J. FOX, CHIEF ENGINEER BUILDIN FOR APPLICANaT TO FILL IN FOR OFFICE USE.ONLY BUILDIN ..thy .DISTRICT NO. - P/LA/N CK. NO. - PE/.R,M/IT pyN�O. ADDRESSG �iJ��j. J 'T a 7. - LOCALITYRECEIVED:jY DATE ❑FAPPL. DATE ISSUED NEA CROSS ST. ry U ' .I BUILDING.. ./. 2 rO�� Y ►�. ' , ADDRESSOWNER ADDRESS / . ,1Aso.ttbg Vt b- - J .• — f .. LOCALITY ♦ .Q,yt/�1//�//mac/`,,&'-,�1/� . .CITY So,!i i�-�.6.of NO�u a d CROSS ST GROUP T FIRE NO.OF y{/ TYPE ARCHITECT OR - TEL. ZONE- I PLANS ,. I J ENGINEER - _ � NO. fes+ /p( BLDG.. ORD. NO. _ ADDRESS y' SETBACK LINE ,•• TEL. - APPROVED CONTRACTOR _,,.AV - NO. - BY - DATE v USE /APPROVED. ' _ADDRESS ' ZONE BY - DATE LEGAL 'DESCRIPTION 'I LOT NO. .12 I BLOCK - _ CORRECTIONS' - TRACT TS _ . SIZE OF LOT (�a3S 1,W /� '$.• I NOW ON LOjj�e, ' USE OF I NO.OF I 'NO..OF - EXISTING BLDG.'- FAMILIES ROOMS - - DESCRIPTION OF WORK NEW x ALTERATIONADDITION REPAIR .ypM p OVING DEMOLISH - L7 - 5 or ZEFT. o�A i -�. I ROOMS 4 ` STORIES / .p r WALL -COVERING � r '� �j !I COOVERING f/, ,S' . USE Or NEW �..�cl`•�d e- �-T+:J BUILDING I HEREBY ACKNOWLEDGE THAT i .,HAVE READ THIS APPROVALS APPLICATION AND-STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION, INSPECTOR y� DATE � AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES _ FORMS, MATERIALS '{jJ�'�,/�`�!-�,(/0 AND STATE LAWS REGULATING BUILDING CONSTRUCTION. S, BRACING. BOLTS., - - .r FRAME: FIRE STOP �/I, ¢•y SIGNATURE OF ; - I OWNER. s� LATH, INT.: , A- AUTHORIZED -Ay.AVF • LATH, EXT.: Nr �- P. C. s PLASTER, INT. ' ®:-o / /2 FEE PLASTER, EXT. .VALUATION O 3 v} 00 FEE ',6 —^ I FINAL l�'-"' •�'`l��I I DEPARTMENT OF BUILDI#G A-iD SAFETY APPLICATION FOR PERMIT mm COUNTY OF LOS ANGELES WM. J. FOX, CHIEF�-ENGINEER FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY �o _ DISTRICT NO. PLAN CK.NO. PERMIT NO. BUILDING l�xx^ m Co'.� ADDRESS t�'p_m LOCALITY �f� RECEIVED BY DATE OFAPPL. DATE ISSUED -d�.y�.�-^1e�-,�..�_� 2-„ NEAREST CROSS STBUILDING . 4� '�7.nst�.•'/� �p OWNER ADDRESS MAIL ,.y CA. LOCALITY ADDRESS Y 4- f�/�� -�yy NEAREST (� p /.� ! -/` TEL ..r plY 1 1 "7/ CROSS 3T. �..r'v-j'-�-;�• -'L�- -� -�I`j t- -: -CITY �•^Yy -.,+.e�2.i� NO.f�r`r J ,•y'�, FIRE NO.OF TYPE7� GROUPr ARCHITECT OR _ _ TEL. ZONE PLANS-- ENGINEER _ NO. BLDG. ORD.NO. ADDRESS SETBACK LINE -fC/ / , U'�, ,,-7 APPROVED /7 1! d,�� fJ BY DATE CONTRACTOR`f'J ..ti-y�.ry,t.�N O. "Y/'1 7" y USE �1 APPROVED ADDRESS .�q? .� fJ�v . 9w4 ►-�'+f� ZONE,lir BY DATE LEGAL A CORRECTIONS DESCRIPTION LOTNO. _{/' i BLOCK TRACT -- S•TH 7-EQ TflD 417- NO. /TNO.OF SLOGS. SIZE OF LOT / L I NOW ON LOT n��D �",AC96tiLa3 !_�...� lrrOT TD �� •��-4M USE OFNO.OF NO.OF A) s EXISTING BLDG. FA1.IILIES I ROOMS DESCRIPTION OF WORK T , ®<c X;p 7-e-0 4-SWC e NEW ALTERATION ADDITION '�dQP_./4+� E.✓*e 490 E'd yt7�li /NG- /N3 ✓Dt� D cl REPAIR MOVING DEMOLISH A SIZE ROOMS - STORIES G 7;/e N TVQT L d L 49 7' WALL �) -,z^ I ROOF COVERING /�/"r J COVERING �•`-�— �(O�- ,'.f��/� �' �jf 1� s � USE OF NEW.' BUILDING!' /✓ �r-r$-�y"� �}=' -V„ -w''+cs.Sop�:�� 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FOUNDATION:. LOCATION INSPECTOR / DATE FORMS, MATERIALS �S AND STATE LAWS REGULATING BUILDING CONSTRUCTION. FRAME: FIRE STOPS, SIGNATURE OF' ,�� BRACING,BOLTS PERMITTEE LATH,INT.: AUTHORIZED AOT LATH,EXT.' DSS-a SOM SETS 7-47 $ P.C.4 PLASTER,INT. v-1 +-�.•" FEE PLASTER,EXT. VALUATION ,FEE FINAL y — APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING D R S I hereby affirm that 1 have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or a certified Z6HA AV—E— C ZIP copy thereof(Sec.3800,Lab.C.) 7 6 LOCALITY-7,w/c Policy NO. Company SIZE OF LOT O.OF BLDGS.NOW ON LOT f"� Certified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. ASSE Q OOK PAGE PARCEL Date Applicant Q SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' o R TEL.N COMPENSATION INSURANCE e' 6: s- WITHIN 1000 FT.OF SCHOOL? ves No ADPRESS (This section need not be completed if the permit is for one hundred DISTRICT GROUP TYPE CONST.' FIRE ZONE PR CES SED Y dollars($hat or less.) I ZIP [moo(/ I certify that in the performance of the work for which this permit J m o 19 is issued, I shall not employ any person in any manner so as t0 AR HITECT ENGINEER TEL.NO. r 31 become subject to the Workers'Compensation LBWS. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL.NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL SIDE P LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS n- L p hereby affirm that I am licensed under provisions of Chapter 9 SQ.FT SIZE NO.OF STORES NO.OF FAMILIES SEWER MAP (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. NEW BK PG , U DESCRI ON OF ORK ADD ❑ License Number Lia Class � � VALUATION LU Contractor Date � ALTER El $16 Z s ""'�9 rn 10 REPAIR C3 — ❑ I am exempt under Sec. $ • B.BP.C.for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXI TING BLDG. 1 . URM ❑ rneo_ Signature AP I NT(PRINT) TEL.NO. LDMA Perm# Z El 1, as owner of the property, or my employees with wages as f e their sole compensation,will do the work and the structure is ADDRESS "�m Q i(_. 044 not intended or offered for sale (Section 7 , Business and / FINAL Professions Code.) WILL THE APPLICANT O NTNG AEBUILDING OCCUPANTHANDLEEQUAL TO O RGRE ATERIAL AID OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q + -F Tom'-5i^ ❑ I, as owner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL � 1 .Ii I;I licensed contractors to construct the project.(Section 7044, YEs❑ NO❑ T• 9< Business and Professions Code.) TOL I�L 1�--�__s � 2__a WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REOUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ' CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST CHECK I-EEK I 1'+C-25 FOR GUIDELINES. I herebyaffirm that there is a construction lending agency for i. AN E 9 g Y YES❑ NO❑ HAA =S�- the performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES m. COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING �1 s Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAININGAPERMIT FROM THE SCAQMD. IIE•.`Iilj—i�3l01 ,•', _j;''-`I_`s 3 Lender's Addresss 4 4 lO OWNER OR AGENT 21 ('1M o31 o' I certify that I have read this application and state that the above P.C.FEE PERMIT FEE information is correct. I agree to comply with all county �/l Ve{l ordinances and State laws relating to building construction,and a. hereby authorize representatives of this County to enter upon ISSUANCE FEE /�'� th mentioned prgpe for in pection p rposes. J3, l/ a INVESTIGATION FEE TOTAL FEE f � sro.awre m AVWIcem«Agent v SEE REVERSE FOR EXPLANATORY LANGUAGE