Loading...
HomeMy Public PortalAbout5622 ROSEMEAD BLVD_Building__ APPLICATION FO'R..RUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN DD EESS I hereby affirm that I have a certificate of consent to self insure, BUILDI D S j or a certificate of Workers'Compensation Insurance,or a certified C copy thereof(Sec.3800,Lab.C.) /`` (��y l� �f LOCALITY I Policy NO. Company SIZE OF LOT NO OF BLDGS.NOW ON LOT ❑ 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. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' , COMPENSATION INSURANCE I 9b ES s T lr' WITHIN 1000 FT.OF SCHOOL? ves No (This section need not be completed if the permit is for one hundred Est dollars($100)or less.) 07JU r DISTRICT GROUP TYPE CONST FIRE ZONE PROC BY I certify that in the performance of the work for which this permit t (d is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. l�Q become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO.Aft DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject t0 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 LICENSED CONTRACTORS DECLARATION SIDE CITY LIC.CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP 12 12 (commencing with Section 7000)of Division 3 of the Business and SO.FT SIZE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW ❑ BK PGC License Number Lic.Class IIP ION WORK Welk Lq t, ADD ❑ VALUATION Contractor Date fJ t ALTER C3 -- C ❑ I am exempt under Sec. REPAIR ❑ F- � �G� $ (; B.BP.C.for this reason DEMOL Elu LDMA P/C# n Date: USE OF EXISTING BLDG. URM ❑ 133153 j# ett. U.C Signature AP A LI N NT) ' LDMA Perm# i i, as owner of the property, or my employees with wages as 0 Z p f.�. y their sole compensation, will do the work and the structure is A D O AC, N s not intended or offered for sale (Section 7044, Business and FINAL DATE Q ({y: 5� ' Q �L•J 1.1 •� �O•�0 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZ RD RIAL 10-2-6- OR A MIXTURE CONTAINI A HAZARDOUS MATERIAL EQUAL TO OR G TER T N THE J ry ITEMS ❑ I, as owner of the property, am exclusively contracting with FINAL BY AMOUNTS SPECIFIED E HAZARDOUS MATERIALS INFORMATION GUIDE licensed contractors t0 construct the project (Section 7044, YES❑ No / i A.TAL ��,7 o 9 5 Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING 0571.95 "� OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH iti HE'l�� 0571 0 5 CONSTRUCTION LENDING AGENCY COAST AIR OUALITY M¢NAGEMENT DISTRICT 1SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. / CHANGE G R)IIA I hereby affirm that there is a construction lending agency for ves❑ No LTJ,/ �f�'a`! W the performance Of the work for which this permit is issued(Sec. IHA EAD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING a 3097,CIV.C.) CH LIST I UNDERSTAND REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, T ,CHAPT 20 S ON 20. 00 ROUGH 2 140 CONCERNING HAZARDOUS ��(•��f—y([jl�, 9/23/93 Lender's Name T I R NG FOR I APER OM THE SCAQMD. In g`}?ri! i y'. +f°vf Lender's Address 17 i p OWNER OR AGENT cI certify that I have read this application and state under penalty c of perjury that the above information is correct.I agree to comply P.C.FEE �� PERMIT FEE » a with all Gunty ordi as and State laws relating to building �f Yi constru ion nd he by uthorize reWesentatives of this County ISSUANCE FEE �- CD {p/��IS up the a e spection purpo INVESTIGATION FEE TOTAL FEE n C-W-1 of AP m AWt Flo ! (i SEE REVERSE FOR EXPLANATORY LANGUAGE i I APPLICATION FOR BUILDING PERMIT S COUNTY OFL O ANGELES BUILDING AND-SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN su �G ADDRESS l I heieby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS �J or or a certificate of Workers'Compensation Insurance,or a certified 4s, 2— copy copy thereof(Sec.3800,Lab.C.) _ CITY ZIP,t Policy No. 2 -R S_ Com3w� "'a T�w1 C v• `7,I�r(, LOCALITY Company SIZE OF LOT NO.OF BLDGS NOW ON LOT ❑��Certified copy is hereby furnished. NEAREST CROSS ST. L Certif!ed copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. Date Z437'-1,' Applicant ASSESSOR MAP BOOK PAGE PARCEL C✓f�J/' — U SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' `l NC TEL NO.Sn e-1- (! tq S�fl a�lc ;T/�/7,��G �, WITHIN 1000 FT.OF SCHOOL? YES NO COMPENSATION INSURANCE 7 (This section need not be completed if the permit is for one hundred ADDRESS �� X040 //.L l A r_1 D% DISTRICT GROUP &WET. FIRE ZONE PROCESSED BY dollars($100)or less.)I certifythat in the performance of the work for which this permit �ZGG . ZIPc� J t p �Ja7'! 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.ezZ I DWELL UNITS NOTICE TO APPLICANT' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject• to the Workers' CON R /! TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith I 1Cii4(ilj I xSCC ��.( -Cl—/V X7 FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS UP,.NO. P L LICENSED CONTRACTORS DECLARATION `�9✓?� Al'6J4I-AI Rx �� ��9 IS 7 SIDE I hereby affirm that I am licensed underprovisions of Chapter 9 I C I)i&ld'^�'1 /j'I,k LIC.CLASS 3 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and i SQ,FT.SIZE NO.OF STORIES NO,OF FAMILIES Professions Code,and my license is in full force and effect. I NEW BK PG ® a ADD [��J�JSZ� e 3 9 DESCRIPTION OF RK VALUATION Q License Nu ber Lic.Class C ❑ COntractoraRZ4� 11JJo C, Data _Mir 7 F X I b�1, i&V r � ALTER ❑ ❑ I am exempt under Sec. REPAIR ElQ BAP.C.for this reason She,- l -`1a'f KI.Re DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. URM 11CL Signature APPLICANT(PWNT) TEL NO. LDMA Perm# j z ❑ 1, as owner of the property, or my employees with wages as Z ;_ y a their sole compensation, will do the work and the structure is ADDRESS O not intended or offered for sale (Section 7044, Business-and FINAL DATE a .�3i.'; O_ I Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL �� 2 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J i !=.i i• ❑ I, as owner of the property, am exclusively contracting with AMOUNTS'SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY a licensed contractors to construct the project (Section 7044, YES❑ No❑ R > !-!!ni_ ;'�� = €i Business and Professions Code.) j WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING .7•i.:••"y i i,i�! OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH '•1'G'!I': L: ,':�.: CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. I hereby affirm that there is a construction lending agency for �'•?U` YES❑ NO❑ C4 the performance of the work for which this permit is issued(Sec. m I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, a TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. - .. o Lender's Address ill '� ':•y C OWNER OR AGENT c I certify that I have read this application and state under penalty Nc of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE with all ounty ordinances and State laws relating to building constr and here uthorize representatives of this County ISSUANCE FEE ato ent a abo entioned property for inspe tion pu�ooses. CO / Bt^^r- O �J`!) INVESTIGATION FEE TOTAL FEE/� r (/ lure Of AFFOWnt a"1 Q SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION 1 heresy affirm that I have • insure, or a certificate of Workers' certificate of consent to self kers' Compensation Insurance, APPLICATION F®R B U I L®INC PERMIT or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING �C4 ❑ Certified copy is filed with the county building inspec- BUILDING 7 n d r tion department. ADDRESS A Z osam y Date Applicant CITY ZIP LOCALITY /� NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 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 ($100)or less.) OWNER �[ �/jG T �} z � ;USE ZONE MAP I certify that in the performance of the work for which this t NO. >_permit is issued, I shall not employ any person in any manner ADDRESS ©h7 (,`jt o D SPECIAL ' CONDITIONS CL0 so as to become subject to the Workers'Compensation Laws. CITY S Q ZIP (�� �`��-� V oe Date Applicant ARCHITECT OR TEL. DISTRICT I GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE V Exemption, you should become subject to the Workers' r (� ,j w Compensation provisions of the Labor Code, you must forth- ADDRESS / 'lee -t-�%v N with comply with such provisions or this permit shall be TEL• c STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR ��J NO. ;_ CLASS NO. DWELL. UNITS LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic. Class SIZE I STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ n$ A-d / / 0�-` El ADD 1:1I am exempt under Sec. G 77 ALTER Pool B.BP.C. for this reason ( $ REPAIR ❑ Date: U OF EXISTING BLDG. � DEMOL *: Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE 7 I hereby affirm that I am exempt from the Contractor's License Low for the following reaso (Section 7031.5, Business and ADDRESS FINAL 1 Pr f sions Code): PRESENT /� ��1 By a BUILDING 56zz i'_ej?ie .Cr ��,,d e AE•GT°a I, as owner of the.pfopwty, or my employees with ADDRESS wages as their sole compensation,will do the work and " 3303 179°64 LOCALITY the structure is not intended or offered for sale(Section `. 7044, Business and Professions Code.) MOVING TEL. Pilo 1 ITEMS 1 ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. TOTAL -79 o 64 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) CHECK 179°64 CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAL SETBACK LINE WIDTH WIDTH I hereby affirm that there is o construction lending agency for FRONT CHANGE .00 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE 0000-0001 7/12/96P.L. Lender's Name p g /'�/' O e LDMA Ref.H ��•16 1 Ai11 i s P.C. Fee$ Permit Fee 4; � Lender's Address 1 certify that I have read this application and state that the Issuance Fee �/ Z6- LDMA P/C N above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee G/I, 6 LDMA Perm. R and hereby authorize representatives of this County to enter 2 upon t bove-me finned property f r inspection purposes. o SEE REVERSE FOR EXPLANATORY LANGUAGE \ ignatur Applicant or Agent Date