HomeMy Public PortalAbout5318 ROSEMEAD BLVD_Building__ i
WORKERS' COMPENSATION DECLARATION
hereby affirm that 1 have a 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.) ���(�M� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. b l3 ompany 5���/ "'t'1'
❑ BUILDING
Certified copy isreby furnished. - FOR APPLICANT TO FILL IN ADDRESS S3 _8 �' ��!/
Certified,copy is filed with the county building inspec- BUILDING J /� X/, �( .. may.
tion department. ADDRESS l �V
him�4
Date Applicant `^' hCITY ZIP LOCALITY
C T�OF EXEMPTION FROM WORKERS'V! /V NO. OF BLDGT NEAREST
SIZE OF.LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) �A� TEL. USE ZONE MAP
OWNER -?M lUtD NO. NO.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner ADDRESS /' /VI. -p� SPENDITIONS CIAL a
CO
so as to become subject to The Workers'Compensation Laws. � � ,
CITY c1lZIP
Date Applicant ARCHITECT Ok TEL.
ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of CONST. ZONE �
Exemption, you should become subject to the Workers'
Compensation provisioris•of the Labor Code, you must forth- ADDRESS �/ a
with comply with such provisions.or this permit shall be. TEL. STATISTICALCLASSIFICATION. APT. CONDO. N
deemed revoked. CONTRACTOR V� N'' 10. z
LICENSED CONTRACTORS,DECLARATION
d" NOLIC.. ��' � CLASS NO. �ITS
s r�C/
I hereby affirm That I am licensed under provisions of Chapter 9 ADDRESS � SEWER MAP
(commencing with Section 7000)of,Division 3 of the Business G� �Lfrl ' LIC. r
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG. VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number 2, 6-c. Class SIZE STORIES FAMILIES ONE .
,,•• ,',^ / / / A r ��� VALUATION
Contractor v"' 10 ��_ ate ` `� ( DESCRIPTION OF WORK C /1 NEW ❑ $
ADD 11❑1 am exempt under Sec. >' lj0 sl GO ►
/' n, ' ALTER 11B.&P.C. for this reason '� REPAIR ❑ $
USE OF
Dat EXISTING BLDG. {n DEMOL ❑
APPLICANT.
PP.PR INT) ++ ee � TEL. L�_ rL� FINAL
N
OW - UILDER DECLARA ON t t V� C�/" NO. S �-
DATE
I hereby affirm that I am exempt from.the Contractor's License *19,6-
Law for the following.reason (Section 7031.5, Business and ADDRESS FINAL z
Professions Code): PRESENT ,,//��p� L By _
❑ I, as owner'of theproperty, or m em to employees with BUILDING Al-'Y St,AZ6.ry�•, 11P
Y P Y ADDRESS ��"•�•� °�
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY , a- L`�=•_i-
O 7044,Business and Professions Code.) _ MOVING TEL. ITEMS
I, as owner of the property, am exclusively contracting
CONTRACTOR NO.
with licensed contractors to construct the project (Sec- i}fiAi ata 2= 00
tion 7044, Business and Professions Code.) ADDRESS µ�
REQUIRED TOTALS FROM. . EXIST. Gl'E :
CONSTRUCTION LENDING AGENCY Flnve�tigation
YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for' +;:;lfd13E •;j(€
the performance.of the work for which this permit is issued
(Sec. 3097, Civ. C.);
Lender's Name, !I0, -3 I'lIJ
i QV LDMA.Ref. # -r t +! t•:
Permit Fee �` -,1£ ;' AM •°E1r
3 Lender's Address
00,
0
1 certify that l have read this application and state that the Issuance Fee f r. LDMA P/C#
8 above information is correct. I agree to comply with all County .
d ordinances and State laws.r luting to building construction, Total Fee �/ D0 LDMA Perm. #
a and h eby aut rize repres ntatives of this County to enter
upon t e bo tioped roperty for inspection yr os
l SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Applicant or Agent Date /
WORKERS'COMPENSATION DECLARATION
hers.by affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT
insurA or a certificate of Workers' Compensation Insurance,
A or a certified copy thoreof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS .� e
❑ Certified copy is filed with the county building inspec- BUILDING '
tion department. ADDRESS r j
Date Applicant CITY /7 2116 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGt. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOTTEL. �. /p�n- MAP BOOK PAGE PARCEL
USE ZONE MAP
I certify that in the performance of the work for which this OWNER f S - NO.dy y NO.
permit is issued, I shall not employ any person in any manner SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS / T f e CONDITIONS O
CITY [ ZIP U
Date Applicant ARCHITECT dR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GR UP TYPE FIRE PROCESSED Y
Exemption, you should become subject to the Workers' ^ CONST. Z NE I—
P Y I �` -J / U
Compensation provisions of the Labor Code, you must forth- ADDRESS / LtJ
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. r;#4DO. N
deemed revoked. CONTRACTOR NO. q-- Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 1 DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWERAP
(commencing with Section 7000)of Division 3 of the Business and LIC. 9
Professions Code, and my license is in full force and effect. CITY CLASS e BK PG 1 VALIDATION
SO. FT. NO.OF NO.OF CHECK
License Number 15 a Lic.Class SIZE STORIES FAMILIES ONE
/ NEW VALUATION
f/tom /N Date — DESCRIPTION OF WORK ADD ❑ $
Contractor O
❑ I am exempt under Sec. ❑ ,
ALTER -20939A
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF DEMOL ❑ # o'o;o a 23
EXISTING BLDG.
APPLICANT TEL. /� ^ ® o 4 9,4
Signature PRINT `w NO� FINAL (j(j
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License 0 0 0 4 9,4,1 V
Law for the following reason-(Section 7031.5, Business and ADDRESS >-446/. MX,0e4c .S 9-- FIN
Professions Code): PRESENT BY ( 0.1 9.d88
❑ I, as owner of the property, or my employees with BUILDING
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.
❑ Poo-
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).
REQUESETBCK FROM
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP.LIINE WIDTH e q q
I hereby affirm that there is a construction lending agency for FRONT # ♦„6,$ ��
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE 10 o 6 a 6 3
P.L.
Lender's Name x 0 0 6&6 3 C5
m P.C. Fee$ Permit Fee J i3 LDMA Ref. A 1 1,22-88
Lender's Address
oI certify that I have r d this application and state that the Issuance Fee
above information is co ect. I agree to comply with all County Investigation Fee y�
0 ordinances a fate I . s relating to building construction, Total Fee nJ LDMA Perm. It
and hereby Jar' esentativesof this County to entupon the abproperty for inspection purposes.
PIP
!Qor
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnat o r Mn ant Dote
V......Y COMPENSATION DECLARATION
f WCompe of ensation oconsent
insure+oraa certif carte oWorkers' pensat Insurance, APPLICATION FOR BUILDING PERMIT
or a certified dopy thereof (Sec. 3800, Lob. C.)
o. d- Company
5;7,4T-=5;7,4T-= �u�6 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N
® Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ✓�)(j
ADDRESS ! (�
Certified copy is filed with the county building inspec- BUILDING �/
tion department. Q J ADDRESS _5312?
f�J 7.
Date /—/-UOpApplicant T,7-- /0' CITY 3LC (��f/ ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM W KERS' O:OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK P E PARCEL
TEL. USE ZONE MAP
I certify that in the performance of the work for which this OWNER TO/4W NO. NO. _
permit is issued, I shall not employ any person in any mannerc �/J SPECIALi
so as to become subject to the Workers'Compensation Laws. ADDRESS 9R-1 7p ( rj�� CONDITIONS O
CITY /7 L /4_ ZIP V
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP TYPE FIRE PRO SSED BY O
ENGINEER NO. CONST. Z E I"'
Exemption, you should become subject to the Workers' V
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be CL
p TEL. STATISTICAL CLA IFICATION APT. DO. N
deemed revoked. CONTRACTOR ri/I /N NO. Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. AW3 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 and LIC. SEWER P
Professions Code, and my license is in full force and effect. CITY CLASS BK PG O 1 VALIDATION
R SO. FT. NO. OF NO.OF CHECK 1
License Number" ?� Lic.Class r✓ SIZE -,c:0U STORIES FAMILIES ONE
VALUATION
�[ '/ / DER ��
Contractor //�0 Date DESCRIPTION OF WOK 3��S—u NEW :291 �,0 A
ADD $
1 am exempt under Sec. ALTER # 0 0 0 0 0
B.BP.C. for this reason REPAIR $ 1 o - 6050
Date: USE OF DEMOL
EXISTING BLDG. 0 0 o60,505
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT NO. DATE O ll 5 88
1 hereby affirm that I am exempt from the Contractor's license
Law for the following reason (Section 7031.5, Business and ADDRESS FI
Professions Code): PRESENT
BUILDING
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 sole(Section LOCALITY
7044, Business and Professions Code). MOVING TEL.
1, 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).
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP.SETBALINE CK F 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.). SIDE
P.L.
Lender's Name
� LDMA Ref. #
m P.C. Fee$ Permit Fee r
Lender's Address
3
g 1 certify that I have read this application and state that the Issuance Fee S kDA P/C#
above information is correct. I agree to comply with all County Investigation Fee
0 ordinan s and State laws relating to building construction, Total Fee be . .
N and he e y authorize re7esentatives of this County to enter LDMA Perm. #
upon t e above-mentid property-for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur of Applicant or Agent Date
9- At. yr L6W 15 Y' Ml-#-
S;COMPENSATION DECLARATION
hereaffirm,erifhdt IL haver certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure,, or_o�certificate of Workers' Compensation Insurance,
or a certified-copy thereof (Sec. 3800, Lab. C.)
� p COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. � '
0 Company —lice
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING /
ADDRESS !
❑ Certified copy is filed with the county building inspec- BUILDING63
i/ /��/-�
tion department. s ^ ADDRESSJffVl 6 D,
Q Q �( w , .
Date / `� r� v Applicant CITY w zip LOCALITY
ERTI CATE OF EXEMPTION OM WORKERS' .OF BLDGS. rrNEAREST
COMPENSATION IN RANCE SIZE OF LOT 01 6 1 �� NOW ON LOT QUIZ CROSS ST.
(This s ction need not be complet if the permit is for one _. ASSESSOR
hundred dollars ($100)or less.) TRACT /, /BLOCK LOT NOQQ' MAP BOOK PAGE PARCEL
SE ZONE MAP` /J/!/ y" ,t. J _ /
I certify that. in the performance of the work for which this OWNER NO. NO. / v�(�
permit is issued, I shall not employ any person in any manner /+ / �- �' (n 2, SPECIAL O
so as to b come subject fo the Workers'Comp sati Laws. ADDRESS Z SD S r' rY v CONDITIONS
` ,ff ZIP" :
Date 3
T. Applicant W CITY IX
NOTICE TO PPLICANT: If, offerrubject
ihi Certificate of ARCHITECT OR , ,^^ J TEL•- DISTRICT GROUP TYPE FIRE PROCESSED BY O
ENGINEER _ V /V :- _ NO. Z CONST. ZONE U
Exemption, fou should becomto the Workers' nCompensation provisions of the e, you must forth- iE5S_�- _'_Z' D' r' ( jC Lilwith comply with such provisios permit shall be
J TEL STATISTICAL CLASSIN ATION APT. CONDO. Cf)
deemed revoked. CONTRACTOR r LL NO i 7 v
LICENSED CONTRACTORS DECLARATION LIC..:"
IC• o CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Z ' NO.
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER P R/�
Professions Code, and my license is in full force and effect. CITY A CLASS BK.SEWER
j VA ID7A1'16N�A
((i SQ. FT. ! NO.OF NO.OF CHECKo 0 0 0
23
License Number yJ Lic.Class SIZE 14jot6 STORIES FAMILIES' ONE VALUATION 3 1 1 9.29
Contractor Dote I DESCRIPTION OF WORK '•_ jj.ti"NEW
A p'' ❑ $ ® 0 3, 1 1 9,2 9�y
I am ex mpt under Sec. ! ( ✓✓ 4�� d eL' 4 �
ALTER ❑
B.BP.C. or this reason r�l ) REPAIR ❑ s � # - 382
a J
Date; USE,EXISTING BLDG. vV �r" DEMOI ❑ vvv ✓✓✓
Signature APPLICANT ,1 JU TEL.NO. 2 Z - FINAL js ° ° 38250'
PRINTzkwj vv
OWNER-BUILDER DECLARATION DATE 7-9!
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and ADDRESS Z /' FIN
Professions Code): WRINTBY 91 11,3A
❑ BUILDING S �"�3 32 V. OS�f�Jf�.
I, as owner of the property, or my employees with ADDRESS 0 0 0 0 0 1
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section [AD
LITY ® )• 4 1 3 0 2 5_
7044, Business and Professions Code). ING TEL. D r 1
❑ 1, as owner of the property, am exclusively contracting RACTOR NO. �, •' _
with licensed contractors to construct the project (Sec- ESS UUU 000
tion 7044, Business and Professions Code).
FROM
CONSTRUCTION LENDING AGENCY BACKK YARD HWY TOTAPROPAIINE WIDTH `
I hereby affirm that there is a construction lending agency for ONT
the performance of the work for which this permit is issued . '
(Sec. 3097, Civ. C.). E '
.
Lender's Name
ee$ Permit Fee LDMA Ref. q
Lender's Address
I certify that I have read this application and state that theIssuance Fee LDMA P/C tkabove information is correct. I agree to comply with all County tigation Fee +�
0 ordinances and State laws relating to building construction, Total Fee ._! a? 5 LDMA Perm. a
and hereby authorize representatives of this County to enter
m upon tin above-men ' ned roper for inspection urposes.
a C✓
� �D 8,g SEE REVERSE FOR EXPLANATORY LANGUAGE
Sin ature
of Applicant or Agent Da
WORKERS' COMPENSATION DECLARATION ��t . 2�'
hereby affirm that I havecertificate 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. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.J� Company �T�7ct- �tt�D
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS 5318-5328 Rosemead Blvd . �J
Certified copy is filed with the county buildin inspec- BUILDING
tion department. ADDRESS 5318-5328 Rosemead Blvd . Temple City, CA 91780
Date - Applicant CITY Temple City zip `: 91780 LOCALITY
CERTIFICATE EXEMPTION NEARESTNO. OF BLDGS.
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. Las Tunas Dr .
,
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. USE ZONE MAP
I certify that in the performance of the work for which this OWNER DollChen N0.2$ - NO.
permit is issued, I shall not employ any person in any manner 'L SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS - �• CONDITIONS
DatApplicant CITY Temple City zip 91780
e
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP I TYPE FIRE PROCESSED BY
Exemption, you-should become subject to the Workers' ENGINEER NO. �� CONST ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO
deemed deemed revoked. CONTRACTOR Si —]ExpreSS N6443-1606
LICENSED CONTRACTORS DECLARATION LIC CLASS NO. �'�' DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 2446 Merced Ave . NO. 506
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP
Professions Code, and my license is in full force and effect. CITY So. El Monte CLASS C 4 5 BK PG VALIDATION
506392 _ C 4 5 SIZE FT STORIIEES 2 AMIDES CONEK 0
CL
License Number Lic.Class U
VALUATION
Contractor
Frendy Lin Date 2-2$-89 DESCRIPTION OF WORK NEW U
_392,
;
❑ I am exempt under Sec. ADD ❑ „-
❑ �Z JL # i '
ALTER 'j') i
B.BP.C. for this reason �T F ij
REPAIR ❑ s ri ����f +
USE OF 1 ^
Date: EXISTING BLDG. DEMOL ❑ ,
Signature APPLICANT TEL. FINAL ri
PRINT) N0442-1DATE t i t��
OWNER-BUILDER DECLARATION �-, r 114 I.j- )!L:.
I hereby affirm that I am exempt from the Contractor's License -746
t a t n'
Law for the following reason (Section 7031.5, Business and ADDRESS 2446 Merced Ave . S .El Mont FINAL 1-''� -L HM '
Professions Code): PRESENT By
r_1
BUILDING
I, as owner of the property, or my employees with ADDRESS V.
wages as their sole compensation,will do the work and '
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Profess ians'Code).
REQUIRED TOTAL SETBACK FRO” EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
.I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name L�
m Lender's Address
P.C. Fee$ �1* •- Permit Fee e.75 LDMA Ref. #
I certify that I have read t is application and state that the r
o Y PP Issuance Fee D LDMA P/C#
o above inforAte
' agree to comply with all County Investigation Fee. '']
o ordinances ting to building construction, Total Fee 00� / Q LDMA Perm. #
o and herebytives of this County to enterupon the arty for inspection purpos
/r SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of A litant or Agent pate
WORKERS' COMPENSATION DECLARATION
insure, oraa certificate of Workers' Compensat on Insurancffirm that I have a certificate f consent to e, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES. BUILDING AND SAFETY
Policy No. Company —{'ate—
❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING 2 p
PY Y ADDRESS �J I� b,�-Q.N'��`-� D
Certified copy is filed with the county building inspec- BUILDING i t ! B I
tion department. ADDRESS > > GL '7y�
-?/) ►,/- 2/ 1 �I,l CITY a ZIP ( //,J LOCALITY
Date c-:4--F--Applicant NO. OF BLDGS.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT NEAREST
CROSS ST.
COMPENSATION INSURANCE ASSESSOR Qpm
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK 53 PAGE b/
O PARCEL 64-
hundred dollars ($100) or less.) TE �y+p
OWNER C1�d NAM—U a USE ZONE MAP
I certify that in the performance bf.the work for which this NO.
permit is issued, I shall not employ any person in any manner ADDRESS , _ SPECIAL
CONDITIONS
so as to become subject To the Workers' Compensation Laws. O
CITY �L� ZIP U
Date Applicant ARCHITEC OR TEL. 0
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP C E ZONE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers' ��' p U
Compensation provisions of the Labor Code, you must forth- ADDRESS CJ+�4 '�
with comply with'such provisions or this permit'sholl be T L. 2 7-7STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR lt/►�� ( Z
LICENSED CONTRACTORS DECLARATION I orLIC. CLASS NO.�DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS j�� v �-- NO. kD '
(commencing with Section 7000)of Division 3 of the Business �.
LIC. SEWER MAP
and Professions Code, nd my license is in full force and effect. CITY S, CLASS L � BK PG VALIDATION
y /t `C/ SQ. FT. NO. OF NO. OF CHECK
�
License Number T Lic. Class CAI SIZE I STORIES FAMILIES ONE
VALUATION
Contractor e-S L Date 3 1- DESCRIPTION OF WORK NEW
❑I am exempt under Sec. Z Ir `� // ' , ADD $
%ALIJER ❑
B.BP.C. for this reason S I /7tL V f Ut AIR ❑ $
Dater USE OF
EXISTIN BLDG. DEMOL ❑
Signature APPLICANTJ TEL. - L / FINAL
OWNER-BUILDER DECLARATION (PRINT). 9 LJ NO. y '�b
I, DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESS �- JCT V Q �� /(
Law for the following reason (Section 7031.5, Business and � FINAL
Professions Code): PRESENT By ';y3 a
BUILDING
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure Wnot intended or offered for sale(Section LOCALITY l^
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-
tion 7044,.Business and Professions Code.)- ADDRESS `i. L^.F.. u j
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCYSET BACK YARD HWY PROP. LINE WIDTH ���� kt '_`•',I
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.). SIDE
P.L. s:1" -Yl: f.•',�1 f�7
Lender's Name s _ W
/ / LDMA Ref. #
P.C. Fee$ IOC Permit Fee
Lender's Address ,
0
I certify that I have read this application and state that the Issuance Fee LDMA PTC#
above information is correct. I agree to comply with all County Investigation.Fee
8 ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
a and hereby authorize representatives of this County to enter
upon the mention grope ty for inspection pure es.
_ Lk
3 L
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or-Agent Date
.. APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
BUI DING ADDRESS
1 hereby affirm that I have a certificate of consent to self insure, d
,r (�V L��
or a certificate of Workers'Compensation Insurance,or a certified, .` CI Y ZIP ��' '
53
copy thereof(Sec.3800,Lab.C.) 1 /`
LOCALITY: /t.
Policy No. Company SIZE OF OT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. j °f/yo EAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOf NO. / USE E MAP NO.
department.
Date Applicant AS ESSOR MAP BOOK PAGE PARCEL — _ CIAL CONDITIONS
OWNER dp S TEL.NO. kyr 0
3 _
/
CERTIFICATE OF EXEMPTION FROM WORKERS'. _vv6 YES NO
COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL?
A(DDRESS
(This section need not be completed if the permit is for one hundred DISTRICT eGROU TYPE CONST' FIRE ZONEXPESSEDB114.
Y
dollars($100)or less.) CITY ZIP
D
I certify that in the performance of the work for which this permit % I
is issued, I shall not.employ any person in any manner so as to ARCHIT OR EN INEE JP.� �{t" TEL.NO. /g)
beco s jec to the Workers'Compensation Laws. � Q� vVi ATISTICAL CLAS KATION PT
Date Applicant Rili/C �� ADDRES ! f vA CLASS NO. DWELL UNITS
NOTICE TO APPLICANT: If, after making this Certificate of / a a REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR TE .N 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 SIDE
a
U
I hereby affirm that I am licensed under provisions of Chapter 9 SQ.FT SIZE NO.OF STORES NO. FAMILIES SEWER MAP
(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
License Number Lic.Class
DESCRIPTION OF WORK ADD ❑ VALUATION W
a
VP Contractor DateALTER ❑ �` z
-
❑ I am exempt under Sec. REPAIR ❑
B.BP.C.for this reason DEMOL ❑ LDMA P/C#
Date: USE OF EXISTING BLDG. URM ❑
Signature APPLICANT(PRINT) TEL NO. ` LDMA Perm# Z y[. g
❑ I, as owner of the property, or my employees with wages as Q I>dm b pO °
their sole compensation,will do the work and the structure is ADDRESS- FINAL D �.,0*7 71.01
O /®�
not intended or offered for sale (Section 7044, Business and Q _rte
1 � }''�
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL V I I EN
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q q
❑ I, as owner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY j_It i
licensed contractors to construct the project.(Section 7044, 4
Business and Professions Code.) ves El NO C _1% f ° L
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
10
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH °��I
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST (, �j>
FOR GUIDELINESr.7f/
I hereby affirm that there is a construction lending agency for YES El NO
the performance Of the Work for Which this permit IS ISSUed(SBC. I HAVE HEAD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD 0000-0001
i"1'1 00E
3097,CIV.C.), PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES.. I„){, —I,00 1 7 I
m. COUNTYCODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING
ip Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 0941 1 AI e3 e y I i
a. Lenders"Address
OWNER ORAGENT
o 1 certify that I have read this application and state that the above
g information is correct. I agree to comply with all county RC.FEE PERMIT FEE
a ordinances and State laws relating to building construction,and
a. hereby authorize representatives of this County to enter upon ISSUANCE FEE' O
the above-men' ned prope�forpection purposes. r� es � �)s� INVESTIGATION FEE TOTAL FEE
o oro,Age oor
SEE REVERSE FOR EXPLANATORY LANGUAGE
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 1306120032
PHONE: (626) 285-0488 EXT:
LEGAL ID: NO. OF CONST BUILDING ADDRESS:
ON FILE SQ. FT ' STORIES TYPE 5318 ROSEMEAD BL
STRUCTURE: 90 V-B SGAB CA 917762211
(ASSESSOR INFORMATION NUMBER: _ NEAREST CROSS STREET: BROADWAY
15388-010-004 THOMAS PAGE: 596 GRID: H4 LOCALITY: TEMPLE CITY CAI
TENANT: (EXIST BLDG USE: COMME USE ZONE: C-2 (ISSUED ON: PROCESSED BY:
(EXIST OCC GRP: 106/12/13 SR
(OWNER: TEL. NO: JBLDGS. NOW ON LOT: VALUATION: IF AL TE FIN BY: CODE: 1
ILU, ANNIE (626) 348-3689- 1 25,000 ^`
5318 ROSEMEAD BL
ISGAB 917762211 FEES PAID ISCRI TIO_ OF WORK
I (TEAR OFF ROOFING LAYERS ON OTEL. REPLACE ALL DRY-ROTTED
IIFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: JWOOD AS NEEDED NAIL DOWN THE THIRTY POUND A.S.T.M. FELT
(APPLICANT: TEL. NO: I (INSTALL THE CLASS "A" TORCH-ON ROLL ROOFING MATERIAL (1:12 *�
(MARTIN, BLAKE (626) 333-5615- IAA BLDG PERMIT ISSUANCE 27.80 1
507 N AZUSA JAB STATE GREEN BLDG FEE 25000.00 VAL 1.00 (SPECIAL CONDITIONS:
ILA PUENTE CA 91744 JAE STRONG MOTION OTHER 25000.00 VAL 5.30
J D2 PERMIT W/O EN-HC 25000.00 VAL 468.60 1 1
TOTAL FEES 502.70
(CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE 1
JREXWAY ROOFING, INC. (626) 333-5615-
1507 N AZUSA AVE STE C LIC. NO ILOCATION AND SETBACKS
ILA PUENTE CA 91744 655986 * 1_
(SOILS ENGINEER APPROVAL
JARCHITECT OR ENGINEER: TEL. NO: j FOUNDATION/TRENCH FORMS
1 LIC. NO: 1 ISLAB/UNDER FLOOR 1
RAISED FLOOR FRAMING
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: I JUNDERFLOOR INSULATION
1 3 001 1 1
FLOOR SHEATHING
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
NO 22 IROOF SHEATHING
SCHOOL WITHIN HAZARDOUS ISHEAR PANELS v
JAIR QUALITY: 1000 FEET MATERIALS
J NO NO NO I FR7U`E INSPECTION
IFIRE SPRINKLER HANGERS
(INSULATION/WEATHER STRIP
JINTERIOR LATH/DRYWALL
(EXTERIOR LATH
RATED FLOOR/CEIL ASSEM.
IRATF.D WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
I �
IT-BAR CEILINGS 1 1 1
J I* ADDITIONAL DATA ON FILE
LOT DRAINAGE
REPORT ID: DPR261 ROUTE TO: BS0508
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS TENANT IMPROVEMENT
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1303180040
PHONE: (626) 285-0488 EXT:
(LEGAL ID: NO. OF CONST NEW BUILDING ADDRESS: 1
ON FILE SQ. FT STORIES TYPE OCCUP GROUPI 5318 ROSEMEAD BL 1
1 (STRUCTURE: 600 2 V-B B I SGAB CA 917762211 1
(ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: 1
15388-010-004 I THOMAS PAGE: 596 GRID: H4 LOCALITY: TEMPLE CITY CAI
I I
(TENANT: IEXIST BLDG USE: COMME USE ZONE: (ISSUED ON: PROCESSED BY: I
IEXIST OCC GRP: B - 103/20/13 SR I
I I I_ I
(OWNER: TEL. NO: 1BLDGS. NOW ON LOT: VALUATION: IF L DATE F`IINNQAL�Y: CODE: 1
18x3 MAI LU (626) 242-3558- i 25,000
16238 BEVERLY DR
ISGAB 917762211 1 FEES PAID IDESCRIPTI N OF WORK I
IT/I LOBBY REMODEL (E) REGISTRATION OFFICE NON-BEARING I
_IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: IPARTITIONS, RESTROOM & PATRON COMMON AREA/KITCHEN I
(APPLICANT: TEL. NO: I I
(YUAN, SAM (909) 980-0358- IA1 PLANCHECK W/EN-HC 25000.00 VAL 458.00 1_ I
17234 RAVENSWOOD PL IAA BLDG PERMIT ISSUANCE 27.80 ISPECIAL CONDITIONS: I
IRANCHO CUCAMONGA IAB STATE GREEN BLDG FEE 25000.00 VAL 1.00 1 1
I _ IAE STRONG MOTION OTHER 25000.00 VAL 5.30
I IB2 PERMIT W/ENERGY 25000.00 VAL 57.5.50 I I
(CONTRACTOR: TEL. NO: IFS INV WORK W/O PERMIT 339.60 DOL 339.60 (APPROVALS DATE INSPECTOR SIGNATURE I
IFENG. CONSTRUCTION CORP (909) 980-0358- 1 TOTAL FEES 1,347.20 1 1
17234 RAVENSWOOD PLACE LIC. NO ILOCATION AND SETBACKS
(RANCHO CUCAMONGA CA 91701 877951 1-
I
I ISOILS ENGINEER APPROVAL 1 1
(ARCHITECT OR ENGINEER: TEL. NO: IFOUNDATION/TRENCH FORMS I I I
LIC. NO: (SLAB/UNDER FLOOR 1 1
IPAISF.D FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: I IUNDERFLOOP. INSULATION II I
1 3 001 1 1 I
IFLOOR SHEATHING 1
INO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS: I
1 0 NO 22 1 (ROOF SHEATHING 1 I 1
1 SCHOOL WITHIN HAZARDOUS I ISHEAR PANELS I
(AIR QUALITY: 1000 FEET MATERIALS 1
NO NO NO I IFRAME INSPECTION
i I
I IFIRE SPRINKLER HANGERS
I i I I I I
I 1 11NSUL4TION/WEATHER STRIPI I
I I
I IINTERIOR LATH/DRYWALL 1 1
I 1 (EXTERIOR LATH 1
I IRATED FLOOR/CEIL ASSEM. I I 1
I I I I I I
1 1 (RATED WALL ASSEMBLIES
1 (RATED SHAFTS/OPENINGS 1 I
I I I I
1 1 IT-BAR CEILINGS I
i* ADDITIONAL DATA ON FILE I 1
1 ILOT DRAINAGE I 1
I ! I I
I (REPORT ID: DPR261 ROUTE TO: BS0508 1
I I I I I