HomeMy Public PortalAbout5546 #207 ROSEMEAD BLVD_Miscellaneous__ \'ORALRS (OMPINSAIION UI ( I NRAIION ';,1A,;,;,I MISCELLANEOUS APPLICATION
hembt a(flml (flat I ImL 1 LLII111LUL Of Llln+tnl tooth COUNI }' OI IOS AINGFLFS WILDING AND SAFETY DIVISION II
I li.sure or a Lerullcate Ill Wodtrs (UmPLns rlSnl In.ul IRLL or
a certified cap) thereof (See i8m Lab C)
a Pullc) No (onlpam FOR APPLICANI TO FILL IN 0.1aaNG , /� 7
® BOI IN D EBS LDORE54 7
Certified LOP) is limb) furnished � � lA b1J_� LOCALITY
I Certified caps is tiled %fill the cowu\ building In 0
pLtu1 CITY zI
p NEAREST
department CROBb 4T
Date \PPIlL 1111 SIZE O1'YF,�LO\ NO OF BLDGS NOW ON LOT DISTRIC No TYPE P SEED BY
1000 D I CONST r
(LRlll 1( All Of EXLMPIION IROA1 NORFsI Iti ra.cr BLocK LOT NO 004
,J <OM PLNSAIION INSUR 4N(l U
mwau STATE MAJOq SECOND LOCAL
(This sctllan med rml be Lompleled If Iht %ork imnhLll ASSESSOR MAPBOOK PAGE PARCEL no r�
b) OIL PLrlllll is flit ort hundred dolLu% 111(RN or It+%) OSLZONE SPECIAL CONDITIONS ;)
v I Lerlll) (Ila( Irl (III pLrittrmll1LL (If (ht %urk ilu nlish fit(, OW NE TEL
pLrmd Is ISSULd I Shall 110( Lmplut ,m) PLIMIll m ml In umLl t r
ul is In bu ono wb)ui 10 16L NOrken ( nrn lgmlllnn I Iw\ ADDRE
OCCUPANCY GROUP
i.
Date ApPIIL un ClT zip
NOTICE TO APPLICANT II IhLI it ding Ihl% (Erolit TIL OCCUPANT LOAD
of Exemption lou should become +ubleLt hl Ill, Wulltr APPLICATION FOR
Compensa(Ion pro\iron+of the Labor(ode )Ou mim Inrth%it11 EXIT HARDWARE
COmPI\ %till MLL11 prinl+oriN (it (ill+ NrIlllt +II 111 III. IIt UTIL,I TRAn ER UIE❑ GEULOGY INSPECTIONLI
' rL+OkLd y� No Spec Know( ❑
❑
' LIC LNSLU CONTRA( FORS DI C I AR \LION OCCUPANCY INSPECTIONS Panic Devices
I hcreb) affirm that I Im licensed undLr pfl%1%io 1+ill (It Ipllr SAFETY PERMIT❑ LIST ITEMS BELOW i
J 9(COmme[ICing%I(IISCUIa1170011)ofl)ltI+ILII111lftla BuM icC \ NO OF EXITS Ej
and Prolessions(odL and til) Ilceme isIn lull IOILL old LIILL T�
- PARKING REO O L� PROVIDED
License Number I IL ( I1ss SPACER
caw Mol DnL LIMITED TIME USE
DATE DATE
I ❑ I 1111 exempt from the Ilcen+mg rLyuutn tni+ as I till FROM TO
3 htemed architect Or a reol+ILr_d plUh,,101111 LnElntu —
r ,
acting m fit) pnlh++un6d t,lpdt lit IhI.hon 711,1 Itu+I til+s mit or No or INSPECTOR b
and PftllLssl1111+ (udL I Exls nNG ul tw __ _FORIL s SIGNATURE
Lie or Reg No D fit PRESENT USE OF BUILDING -INAL APPROVAL
W'
IIUML UWNI R 111111 UI R UI ( I \I( \I ION NO I n 6uaulNce L/Q
VN LOT AND USE
I hereb) allirn ill it I un L\LrIPI Iran IILL (Ont rIL101 + I iLLns_
Law for thl following re ion ISLction 7011 \ Bu+nit++ uul
Professions (ode) NO PARKING �•
E3d\ 01111tr III IIIL P011gill Wit Ili Illi n1Nt 11111 NI SPACES PROVIDED
+trnLltlfL 11 not inlendLd lir olki,d lo, it, 0,,uon 104, PROPVSED USE OF BUILDING
Business and Professions (OCIL)
CSF FN
i CONSTRtI(TION l LNIIING Lt AGl N( 1
henhy all irm Ill 1t there 1+ a con+Il uttiun ILnJme I.Lnu or
the mrformmLL oI the work for Vh1LIl Ihls ptnnll n I+M0.LI —
f (See 1097 (IV ( ) PROPOSEDMAX DEC
I-ender s NamegP!(LICANT 4T IRL'II � TEL NO
J�z �. �aYV 33rb'1
Lenders Ac1Jrt++ ADDRESS
I certify that I hale read [his appllLallal and st lit Ill d [h,.
above Information Is COrrLLI I agrte to LOmPI) x1111 all(OUT I PERMIT FEE
ordinances and State laws relating to budding COII+lrnLIlOn uul
hereby authorize represent dives of Ihn Coon[) IU Ln1Ll uplln ISSUANCE FEE
the above-mullioned proper) For n1sPLLtum purposLs
, TOTAL FEE
J �/v
i X l/�l-d,[_ %l I RI ItLRSL FOR LXPL ANATORY LAN(,tJA(,I-
sifujinaCe of Penn to U%t
f WORKERS LUMrCNJALIV[V LOL_LAKAHUN 30-0oe3DPW12/e0 MIDI.(GLLHIVC,VUz HI''1"'L1l.Al IVIY
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING AND SAFETY DIVISION
f tenure.or a certificate of Workers'Compensation Insurance, or
(� a certified copy thereof(Set 3800 Lad C) - '- - -
POhcy Na Company FOR APPLICANT TO FILL IN 134.111-DiNG
B BUILDING ADDRP S ADDRESS
Certified copy is hereby furnished .�"b Al, "-j,4640 ({l� ��0
LDCALTY
Certified copy is filed with the county budding inspection crry--/ W y —r [t
+ department. 1 ��'Y"�-r el l y ZIP p ' IQo �RRESr
Date n Applicant SIZE OF L� � � NO OF BLDGS NOW ON LOT IAHTRICT No GROUP t� rloceSSaD SY
CERTIFICATE OF EXEMPTION FROM WORKERS ``.
f I COMPENSATION INSURANCE TRACT BLOCK LOT NO ro Ic...i srwre Mw.ioq SECOND I-ouL
(This section need not be completed if the work involved ASSESSOR MAP BOOKof
by the permit is for one hundred dollars ($100) or less.) PAGE MRCEL USEZONS SPECIALCONDRiONS
f I certify that in the performance of the work for which this Lnm
WT.7e1CT?Ot.f TEL NO
I permit is issued. I shall not employ any person in any manner
so s9 to become subject to the Workers Compensation Laws [�E IL-L CHr .q1✓(A /LFA+-7 -ft of OCCUPANCY GROUP �
Q1�9 [/l�
( Date Applicant CITY y� � UIy ZP �I��v
4.
NOTICE TO APPLICANT If after making this Certificate It OCCUPANT LOAD
of Exemption you should become subject to the Workers APPUCATION FOR
Compensation provisions of the labor Code you mutt forthwith EXIT HARDWARE
comply
with such provisions or this permit shall be deemed TRAILER UWE] GEOLOGY INSPEcr1ON❑ No Spec Krrowl ❑
OCCUMNCYIN,sMcT1ON 1C$ Panic Devices ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ IuaT SEMS enDwi
1 I 9(commencing with Section 7000)of Division 3 of the Business lame ot liustuess
and Professions Code and my license Is in full force and effect
PARKING REO D PROVIDED
i License Number Lie Class 'D�2�1 Q�G 0P SPwcee JJ
( Contractor Date LIMITED TIME USE
El 1 am comp[ from the licensing er requirements I aa
licensed architect or a registered professionall m DATE DATE
engineer FROM TC,
acting in my professional capacity (Section 7051 Business size or 1 3 S� S.� no or INSPECTOR a
(- and Professions Code) EX1ST1NG 1LOG sTORISy Z ®cNAT11we.
LiG or Reg. No Date PRESENT Use Or aUILDING FFIf C- FINAL APPROVAL i ,pZ
r HOME OWNER-BUILDER DECLARATION NO OF INIST11,1G W11-01NGS
ON LOT AND USE
1 hereby affirm that I am exempt from the Contractors License
Law for the following reason (Section 70315 Business and
( Professions Code) No MRKING
❑ 1 as owner of the property will do the work and the sMcE rRoviDED
structure is not intended or offered for sale(Section 7044 1 PROPOSED USE Or 13111LOING
Business and Professions Code)
f 1m7oM G r?I—r 09xt c t
i CONST'RUC ION LENDING AGENCY -
I hereby affirm that them is a construction lending agency for
the performance of the wort for which this permit is issued
( i (Sec. 3097,Civ C) PROPOSED MAX OCC
Lender's Name APPU T lr NO
Lender s Address woow C� 7o•/!r17/'v- 2fe-S626
( I certify that I have read this application and state that the is V6 /� (AtdA�IQIw 4'207 TgMtfCr7%" 9/7f
above information is correct I agree to comply with all County PERMS roe
ordinances and State laws relating to building construction and
hereby authona representatives of this County to enter upon ISSUANCE me
i t I the above-mentioned property for inspection purposes. -
TOTAL Tee
% /� S��S/d2 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perl),W Date