The URL can be used to link to this page

Home My Public Portal About5701-5711 ROSEMEAD BLVD_Building__ WORKERS' COMPENSATION DECLARATION hereby olirm that I have certificate of consent to self insuriifiaof Workers' Compensation Insurance, APPLICATION F O R 'B UI L D I N G PERMIT oor• Cerocopy thereof (Sec. 3800, Lab. C.) � �� COUNTY OF LOS ANGELES i BUILDING AND SAFETY Policy No. �a��e Company BUILDING e Let �ertified copy is hereby furnished. I .FOR APPLICANT TO FILL IN ADDRESS ��D/ Certified copy is filed with th u ty building inspec- BUILDING Datedo d partment. ADDRESS a Q Applicant CITY ZIP •Gj�`780 k> LOCALITY r NO.OF BLDGS.. NEAREST CERTIFICATE OF EXEMPTIO FRO WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE.. ASSESSOR (This section need not be completed if the permit is for one ' TRACTBLOCK LOFT MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL ZONE MAP OWNER O• Z13114. - r. 0 NO. I certify that in.the performance of the work for which this -ff,, /I SPECIAL permit is issued, I shall not employ.any'person in any manner ADDRESS C) �YL FO ' V 2 CONDITIONS so as to become subject to the W k-Ae Compensa ion Law I •O -CITY I4 . zip [CJP� ' V Date e�� Applicant l ARCHITECT OR TEL. J: NOTICE TO APPLICANT: If, after ma ng t ' -Certificate of ENGINEER e O L j DISTRICT GROUP TYPE FIRE PROCESSED BY O ` CONST. ZONE (- Exemption, you should become subject,to the Workers' �/ r�rJ w Compensation provisions of the Labor Code, you must forth- i ADDRESS r Gry � !� a with comply with such provisions or this permit shall beC TICAL CLASSIFICATION APT. CONDO.or Z 7lL( ( - , LICENSED CONTRACTORS DECLARATION LIC.deemed revoked. CONTRACTOR p� 4 CLASS NO.��DWELL. UNI I hereby affirm that I am-licensed under provisions of Chapter 9 ADDRESS JQ fL ." NO.��w � LIC. I 'SEWER MAP MEOW (commencing with Section'7000)of Division 3-of the Business i. and Professions Code,and my license is in fuII.force and effect. CIN ;CLASS C-�s BK PG VALIDATION SQ. FT. NO. OF NO.OF' CHECK License Nu r Ur 1' 7O Lic. Class SIZE STORIES FAMILIES • ONE _ VALUATION.. Contractor }%e ! �U! •7 DESCRIPTION OF WORK �i;' NEW ❑ . 1$ � ADD ❑ �� ❑1 am exempt under Sec. I ALTER ❑ i _ BAP.C. for this reason D/V �'� ti/ REPAIR ❑ $' iU`•_I °F _ Date: USE OF }i EXISTING BLDG. DEMOL ❑ 33_7 164.16 Signature APPLICANT TfL. g (PRINT) j FINAL 1 �I �r OWNER-BUILDER DECLARATION DATE -Al -I�_ I hereby affirm that I am exempt from the Contractor's License !F� 16-4. .s Law for the•followirig reason (Section.7031.5, Business and ADDRESSS� FINAL. rLs , Professions Code): PRESENT By kn�L�a 164.1'a BUILDING s I, as owner of the property, of my employees with ADDRESS -G3-ANGE .00 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING � TEL. � r_ ❑ I,as owner of theproperty,am exclusive) contractingCONTRACTOR NO. with licensed contractors to construct.the project (Sec- ADDRESS c=(:;' 1°-`I tion 7044, Business and Professions Code.) �'• �. =,1_. 1�° � REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH' _ r` ' 's ` L3 , I hereby affirm that there is a construction lending agency for , FRONT i "' "" the performance of the work'for which this permit is issued P,L. I : !--:•:. -.7 tiie ' (Sec. 3097, Civ. C.).' � � SIpE. P.L: Lender's Name I, 3 / / J<.-`•" -y p LDMA Ref. # P.C..Fee$ A� Permit Fee aQ Lender's Address 4abov' , I have read this application and state that the Issuance Fee' of / LDMA P/C# _ " iM otion.is correct. I agree to comply with all County Investigation Fee ' ,nd State laws relating'to building construction, Total Fe � LDMA Perm. # uthorize representatives oft is County to enter ve-ment' ' prop fo ' specti uurpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE re of Ap nt or Agent Date A Le i BUILD iN PERT�T � COUNTY OF •S ANGELE /f,�•0� Z�(v- " °� BUILDING AND SAFETY + FOR APPLICANT TO FILL IN BUILDING ADDRESS WORKER'S COMPENSATION DECLARATION gUILDI G D Ess _ 570 •- 5-711 R.oS FLI7 g 2• I hereby affirm that 1 have a certificate of consent to self insure, '�o� 5 I _O S E.tlle , f�, 'I or a certificate of Workers'Compensation Insurance,or a certified (�JIJ II-� ,j copy thereofISec.3PM I Rh.r.) CITY r zIP 1�71 y�3� �/ T�-1 I PLS G-i TY LOCALITY Policy No. Compa�P - SIZE OF LOT NO.OF BLDGS.NOW ON LOT I I NEAR ST CROSS S� G 1 T r �ertifieYl Copy is hereby flIfnished. - 2-11"/f� VA i o j J S I I J L�S L11�?�g T. TRACT BLOCK LOT NO. ❑ Certified copy is filed with the county building inspection 3 2 3 I �-� 3 E L USE ZONE . MAP NO. department. 1 160166 •-! 2 ASSESSOR MAP BOOK PAG PARCEL Date s-- Applicant- -- - 5 3 I Z oilSPECIAL CONDITIONS OWNER TEL NO. j v CERTIFICATE EXEMPTION FROM AN WORKERS+ C HAI-4PI O N DEYEL 1-1. g - gp WITHIN 1000 Fr..OFSCHOOL? YES NO COCOMPENSATIONPEPENSATION INSURANCE is section need not be completed if the ADDRESS _� } (Thp permit is for One hundred 2®D Q(�� .G-r�'f G �Z� /^G•, DISTRICT GROUP TYPE CONST.' FIRE ZONE PROC ESSED BY dollars($100)or less.) CITY ZIPc I certify that in the performance of the work for which this permit L.0 N6r• gam/-614 /O�o- 5� �-� Is Issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. (g)g become subject to the Workers'Compensation Laws. T L4. L_AYIAAJ-l ASSOC I cm 7- 5Z STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO.L—DWELL UNITS ro5 r 5 Y/+,r J N UYs r=3 LVO, \/AdJ OL NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST dTEL.No. Exemption, you should become subject to the Workers' J7& SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith 4 04 FRONT _ comply with such provisions or this permit shall be deemed revoked. APP RESTS - LICNu.. ry Q PL SIDE - �- LICENSED CONTRACTORS DECLARATION _ - _ 0 ;IGCLAss =z .3PL o I hereby affirm that I am licensed under provisions of Chapter 9 a E N RES o. F FAMILIES SEWER MAP 3-'- (commencing with Section 7000)of Division 3 of the Business and Professions Code, and. Iirwnse la in full foroe and effect. I NEW BK PG M:-L 0 p DESCRIPTION OF WORK a P ADD ❑ VALUATION ® LI nseiN� b .!{,=LIc.Class U 1 L� 1 la LOG . o�� n tG�. ' 3r� Date- -- _ ALTER ❑ z 0.13,C, TYPe 5 REPAIR ❑ �_�_..:_. ❑ I am exempt under Sec. t;hANS _ B.&RC.for this reason DEMOL ❑ LDMA P/C p - Date: USE OF EXISTING BLDG. URM ❑ - _ Signature APPLICANT(PRINT) TEL.NO. I i�l_I:—•:_!�I - T.�-1. t AYl,l, b/ S Z_ LDMA PBTRI n - ❑ I, as owner of the property, or my employees with wages as A��' C :.r,_'�•a their sole compensation,will do the work and the structure is ADDRESSf. not intended or offered for sale (Section 7044, Business and G5 I`J vPr14 ILI LLA%f S $LVr FINAL DATE G Professions Code.) WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL 3.0 _ ( I, as owner Of the property, am exclusively contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project (Section 7044, Business and Professions Code.) WILL 11 No 1:1 WTHE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST �J FOR GUIDELINES. q p I hereby affirm that there is a construction lending agency for YES❑ NO❑ /a the performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD m 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES , 'Ll •� - '�•_ COUNTY CODE,TITLE CHAPTER 2.20 SECTIONS 2.20AWTHROUGH 220.140 CONCERNING +�' � I•tl '. : Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. F IT. , •i Lender's Address OMAN OR AGWT o I certify that I have read this application and state that the above i.�' rrj informatio is correct. I agree to comply with all county P.C.FEE ®.� PERMIT FEF, D , .t ordinan and State laws relating to building construction,and -Ss ti t" here uthorize repres tatives of this County to enter upon ISSUANCE FEE I I th ti in Re 1T)^uz^sea � •OGS r`.I r-•I INVESTIGATION FEE TOTAL FEE i'•'• f + 1 un olAq+0mn1 O,A� lu � pyo c / d .•� „ n-• �� '' T) 7SEE REVERSE FOR EXPLANATORY LANGUAGE