HomeMy Public PortalAbout4912 ROSEMEAD BLVD_Building__ r
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
irl pre, or a certificate,of Workers' Compensation Insurance, APPLICATION. FOR BUILDING PERMIT
ortta certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pofin' No. Company BUILDING
❑1 Certified copy is hereby furnished. FO77R APPLICANT TO FILL.IN ADDRESS 4 9/Z AJ A?O Sr � F�LUr�
❑ Certified copy is filed with the county building inspec- BUILDING I
ESS Z A/. SSC � � f�(/�/Q G�
tion department. l P� CI � 7 6.
r �PLt� / ZIP 6 LOCALITY
Date Applicant
NO OF BLDGS.. NEAREST+. 9 / A
CERTIFICATE OF EXEMPTION FROM WORKERS' OF LOT 71 X/L NOW ON LOT 1 NEAREST. o3 ,
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one BLOCK LOT NO.. MAP BOOK 7 O PAGE PARCEL F�
hundred dollars ($100)or less.) TEL. ) USE ZONE MAP !
ER D I�iK// G)-1AA,)6 NO. 5 / NO. �O
I certify that in the performance of the work for which this [ o SPECIAL
permit is issued, I shall not employ any person in any manner ESS L /v,�O�e'.� `c�( r)LL* 3 CONDITIONSCL
so as to become subject to.the Workers'Compensation Laws. / O
CITY le ZIP b
Date Applicant ARCHITECT OR f U TEL.
DISTRICT OUP TYPE FIRE NCESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER dk NO. CONST. ZO E
Exemption, you -should become subject to the Workers' �j W
Compensation provisions of the Labor Code, you must forth- ADDRESS c-/�o�
with comply with such provisions or, this STATISTICAL CLASSIFICATION APT. CONDO. N
p y p permit shall be TEL. Z
deemed revoked. CONTRACTOR NO. _
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business
LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. q7 NO.STORIOES NO.
.ILOIES CHECK
License Number Lic. Class SIZE ✓ ONE
VALU TION
Contractor Date DESCRIPTION OF WORK NEW ❑ S {/�� v
® � ADD
El ® VVOff( ►
I am exempt under Sec. Z3u`� GiGLG(/1'� d'L.t_
ALTER ❑
B.BP.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL FINAL
OWNER-BUILDER DECLARATION (PRINT) �j� f�JG N
DATE
I hereby affirm that I am exempt from the Contractor's License p /
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT By Ar r�T e a
BUILDril;4
MING T
El 1, as owner of the property, or my employees with ADDRESS t
wages as their sole compensation,will do the work and �, �(�+ n+•^t- SWJ + tic
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 ITEMS NO. 111
with licensed contractors to construct the project-(Sec- ADDRESS TOTAL 209 . 25
tion 7044, Business and Professions Code.) Cry1.
REQUIRED TOTAL SETBACK FROM EXIST., CHECK 13 arc
CONSTRUCTION LENDING AGENCY. SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT CHANGE {E
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L. .
Lender's Name. �ryy� y{ i `� 4
LDMA Ref. # 00WJ— CO1 9129
P.C. Fee'$ Permit Fee.-` ✓ C91+} 1 �tt�l��
Lender's.Address
0 1 certify that I have read this application and state that the Issuance Fee . LDMA P/C# ,
above information is correct. I agree to comply with all County Investigation Fee
8 ordinances and State laws relating to building construction, Total Fee—2.r) 7, _2 5 LDMA;Perm. #
a and hereby aut orize rep sentatives of this County to enter.
upon.the o -menti a foperty for ins ection purposes. j
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig tore of Applicant or Age Datly
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0306180043
PHONE: (626) 285-0488 EXT:
LEGAL ID: NO. OF CONST GADDRESS:
ON FILE SQ. FT STORIES TYPE 4912 ROSEMEAD BL
STRUCTURE: VN SGAB CA 917762203
ASSESSOR ORMATI N NUMB : NEAREST CROSS STREET: LOWER AZUSA
5388-021-006 THOMAS PAGE: 596 GRID: H5 LOCALITY: TEMPLE CITY
TENANT: EXIST BLDG USE: R S D USE ZONE: RISSUED ON: PROCESSED BY: EXPIRES ON:
EXIST OCC GRP: 06/18/03 JK 06/12/04
OWNER: TEL. NO: BLDGS. NOW ON LOT: VALUATION: FINAL DATE F AL(BY:
� CODE:
MCDO4912 NELLROSE EDWARD J - 4,456 ('}
4912 ROSEMEAD BL I L VV ----
SGAB 917762203 FEES PAID D SCRIPT ON UF WORK
T/O 3LAYERS OF COMP; INSTALL WEATHERWATCH 30#FELT & 40YR
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: CLASS A MISSION BROWN SHINGLE
APPLICANT: TEL. NO:
BRANDON LUDLOW (818) 590-1211- AA BLDG PERMIT ISSUANCE 27.75
11254 VANOWEN AC STRONG MOTION RESID 4456.00 VAL 0.50 SPECIAL CONDITIONS:
N HOLLYWOOD 91605 D2 PERMIT W/O EN-HC 4456.00 VAL 132.60
TOTAL FEES 160.85
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
MODERN ROOFING (818) 590-2626-
2219 WEST OLIVE AVENUE LIC. NO LOCATION AND SETBACKS
SUITE# 282 B/L RHE
BURBANK CA 91506 SOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER: TEL. NO: FOUNDAT ON/TRE H FORMS
LIC. NO: SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: UNDERFLOOR INSULATION
144H265 3 01
FLOOR SHEATHING
NO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS:
NO 21 ROOF SHEATHING
SCHOOL WITHIN HAZARDOUS SHEAR P NELS T
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO FRAME INSPECTION
REQUIRED TOTAL SETBACK FROM EXIST FIRE SPRINKLER HANGERS
SET BACK YARD: HWY: PROP LINE: WIDTH:
FRONT PL- INSULATION/WEATHER STRIP
SIDE PL-
INTERIO LATH/DRYWALL
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM.
RATED WALL ASSEMBLIES
RATED S A S/0 NINGS
T-BAR CEILINGS
* ADDITIONAL DATA ON FILE
LOT DRAINAGE
REPORT ID: DPR261 ROUTE TO: SS0508