HomeMy Public PortalAbout4916 ROSEMEAD BLVD_Building__ M
/■/j hP17MAPPLICATION FOR BUILDING PERMIT �1
Ttfi!:- �- o COUNTY OF LOS ANGELES BUILDIN AND SAFETY
WORKER'S COMPENSATION DECLARATION F PPLICANT TO FILL IN BUILDING A
BUIL I D R SS
I hereby affirm that 1 have a certificate of consent to self insure,
or a certificate of Workers'Compensation Insurance,or a certified CI ZI t
copy thereof(Sec.3800,Lab.C.) LOCALITY Y
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CR .
El Certified,copy,is filed with the county building inspection TRACT BLOCK LOT NO.
department. USEhhhZONE MAP NO. 141 `� / /�
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL. J SPECIAL CONDITIONS CLx��
CERTIFICATE OF EXEMPTION FROM WORKERS' QWNER T&NO. YES No
COMPENSATION INSURANCE ao�
R SS WITHIN 1000 FT.OF SCHOOL?_
AD %"`/��
(This section need not be completed if the permit is for one hundred DISTRICT GROUP TYPE CONST.' FIRE ZONE OCESS BY
dollars($100)or I ITv ZIP ►✓ o k-3VI certify that in thee pperformance of the work for which this permit F�J r
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. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT..If, after making. this Certificate Of CONTRALTO TEL.NO. REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' SETBACK 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
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS P1L DE o
U
I hereby-affirm that I am licensed under provisions of Chapter 9 SEWER MAP
SQ.FT.SIZE NO.OF STORES NO.OF FAMILIES
(commencing with Section 7000)of Division 3 of the Business and NEW_ ❑ BK PG CD
Professions Code,and my license is in full force and effect. v
DESCRIPTION OF WORK, ADD ❑ VALUATION ® W
License Number Lic.Class w�V W
00
Contractor Date -i 9 ALTERCLOO ❑ � Z
❑ I am exempt under Sec. y� o/� / I� REPAIR
B.SP.C.for this reason
L)pp KEy 5v7�/�(y�9 DEMOL ❑ LDMAP/C#
Data: - - OF EXI TING BLDG. URM ❑ f[ _. •- -s-
1.
Signature AP ICANT(PRINT) TEL. O. LDMA Perm#
❑ I, as owner of the property, or my employees with wages as O EMS
their sole compensation,will do the work and the structure isr F- - 3''
not intended or offered for sale (Section 7044, Business and �j (A t?!FINAL DATE Q A �'' _ •fF 5
Professions Code.)
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL L�-�j J �•I's :=a i•i
❑ I, as owner of the ro ert ,:am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN
P P Y Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY /I �
licensed contractors to construct the project-(Section 7044, YES❑ NO❑ l/_` '_H�l�iGL a
Business and Professions Code.) IL
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH '
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLISTs j _j+ I!� L'1 5 J{>y?^3
FOR GUIDELINES. - '.35.f'-.'.. -•
I hereby affirm that there is a construction lending agency for YES❑ NO❑ " '" i 'tea'I
the performance of the work for which this permit is issued(Sec. 242 r ' ''a=`
the performance
C. . I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD
3097, 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
Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
Lender's Address
ER OR
AGENT
o' I certify that I have read this application and state that the above RC.FEE PERMIT FEE
g information is correct. I agree to comply with all county
3N ordinances and State laws relating to building construction,and
a- eby auth rite r�resentat�ivestpisenter upon ISSUANCE FEE `ab ntiones. I v
a INVESTIGATION FEE TOTAL FEE
Agent
SEE REVERSE FOR EXPLANATORY LANGUAGE,