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HomeMy Public PortalAbout5721-5747 ROSEMEAD BLVD_Building__ APPLI :4ION FOR BUILDING PERLA� �pCOUNTY 01-,L;08 ANGELES BUILDING ARID SAFE' , WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN I .pJWILDII% Ess 7 BUILD GADD � -i �!�/ Q� I hereby affirm that I have a certificate of consent to self Insure, ns EM � or a certificate of Workers'Compensation Insurance,or a certified copy thereGf Seo.380,Lab.C.) / ZIP '570/ )� ,, `7J (�r� LOCAL? LLQ POI? No. mpany,�;���" �""' ' OF L NCV;BL GS.NOW ON LOT d �} NEAREST CROSS ST Certified ceop'y9 hereby furnished. 2 Z V �. ❑ Certified copy is filed with the county building Inspection TIR IC 4 BLOCK D O department. �1 d J 02 0 PrL USE ZONE MAP NO. Det'-19 Applinant 1JG d � ! J U K PAGE©/� CP�3 I ��� / Or _ TEL NO. (J SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' ��'��Y� COMPENSATION INSURANCE _ WITHIN 1000 FT.OF HOOL? YES NO (This section need not be Completed if the permit is for one hundred AD�&4:190NrJ DISTRICT 90UI TYPE CONST'l FIRE ZONE 3Ej�3dollars($hat or less.) Clyr G ZIP19 ►��J /'�v �I certify that in the performance of the work for which this permit �J cJlUoIs issued, I shall not employ any person in any manner so as to HIT OR ENGINEER TEL. O. become Subject to the Workers'Compensation Laws. � STATISTICAL CLASSIFICATION APT CONDO Date Applicant A DRESSCLASS NO. DWELL UNITS NOTICE TO APPLICANT.• If, after making this Certificate ofors s ��� REgUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject t0 the Workers' CO ORNTRACTTEL.NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith a FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.No. PL o LICENSED CONTRACTORS DECLARATION c �� ��� Llc.CLASS SIDE 7� I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (corhmencing with Section 7000)of Division 3 of the Business and FT NO.OF RES NO.OF FAMILIES 4L•j e a Professions Code,and my license is in full force and ct. `/r,Q,2/ NEW BK PG , •yll7 i=� 013 n 7 License Number Lic.Class lI IO wo _�, ADD ❑ vALUAnor j Contractor Date �� '����6 ALTER ❑ � y G, (;FOTAL 1 Ills. ❑ I am exempt under Sec. ��++ p REPAIR ❑ $ }�/�j aOD CHC K •149,00 n 4 2 � B.l£P.C.for this reason V e o f C S f b DEMOL ❑ LOMA PIC%n CHANGE n i jf 1 Date. �—�— USE OF STING BLDG. .URM CHAN ❑ GE Signature _MPL JCANT(PRINT) TEL NO. LDMA Perm li ❑ 1,as owner of the property, or my employees with wages as . t9G. Z"' p 0000-000115`1 i .tj % :i their sole compensation,Will do the work and the structure is DRESS F not Intended or offered for sale (Section 7044, Business and C✓ FINAL sDATE �J C 774 1 AM 10: n tom: Professions Code.) WILLTHEAPPLICANTORFUTUREBUILDINGOCCUPANT HANDLEAHAZARDOUS MATERIAL ]� OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN a I, a3 owner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL licensed contractors to construct the project.(Section 7044, YES❑ NO❑ Business and Professions Code.) WILL THE INTENDED USE THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT RFAUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH CONSTRUCTION LENDING AGENCY CO Gj,AIR DEL QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST " I hereby affirm that there is a construction lending agency for YES❑ ND 11L I the performance Of the Work for which this permit is ISSUed(SBC. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD ��/ t'FI 4.i -? t"+ "i '�'•) Tr "'` 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES t i '. -p �� ' ' COUNTY CODE,TITLEZ CHAPTER 2I0 SECTIONS 220.100THROUGH 2.2MI40 CONCERNING '�'� '"_ Lenders Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. �•�� 7 3 Lenders Address OWNER OR AGENT o I certify that I have read this application and state that the above P.C.FEE PERMIT FEE information is Correct. I agree to comply with all countyO7" ordinan and State laws relating to building construction,and � d he author, p n ' es of his County to ente u on // // Q ISSUANCE FEE o?3 A above-m ti ed rop for spection purposes. P , �. (p(G. % /3• �;(�7 :nT. •`.'` wsa ' I ESTIGATION FEE TOTAL FEE ® /O OG q s y f-i O`' i SEE REVERSE FOR EXPLANATORY LANGUAGE. w r:t •i ''' '•' ' WC6' COMPENSATION DECLARATION /�,/ hereby affi at I have r certificate of consent to self APPLICATION FOR BUILDING P E R insure, or a certificate of Workers' Compensation Insurance, or a certified copy there�D(�e�3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. //o:/�/ Company �✓ a6lwa 4 BUILDING ❑ Certified copy is hereby furnished. A"A FOR APPLICANT O FILL IN ADDRESS gwJ( 0"Certified copy is filed with the county building inspec- BUILDING /IO/ tion department. ADDRESS / �y q ` C LCA Date //'f� Applican CITY ZIP LOCALITY NO.OF BLDGS. NEAREST CERTIFICATE OF EXEM �INFROMWRKERS' 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.) TEL. OWNER /Q /iG{�. NO. USE ZONE MAP I certify that in the performance of the work for which this /� 11 NO. permit is issued, I shall not employ any person in any manner ADDRESS x4eO COND TIONS a- so as to become subject to he W r' ompensation Laws. O CITY zem-:, $�iSyGf� ZIP V mate Ap ✓ n ARCHITECT OR T DISTRICT GROUP TYPE FIRE PROCESSED BY 0 NOTI E T APPLICANT: If, after ma ing this Certificate of ENGINEER N — O Exemption, you should become subject to the Workers' CONST. Z NE U Compensation provisions of the Labor Code, you must forth- ADDRESS �� GZ a- with comply with such provisions or this permit shall be TEL. / STATISTICAL CLASSIFICATION APT. O. N deemed revoked. CONTRACTOR/,W.!;V4e t le- NO. S+i CONDZ LICENSED CONTRACTORS DECLARATION // LIC. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS l0 3 �i L T/� o T N 5� (commencing with Section 7000)of Division 3 of the Business LIC, SEWER MAP and Professions Code,and my license is in full force and effect. CITY L�/90//� �/ CLASS BK. PG VALIDATION , SQ. FT. NO. OF NO. OF CHECK License Number45 d 77 l Lic. Class � SIZE STORIES FAMILIES ONE Contracto&,f5171Ydy"C�Date DESCRIPTION OF WORK EW ❑ VALUATION Elam exempt under Sec. ADD El $ ► --�� p� ALTER ❑ B.&P.C. for this reason ZZ. REPAIR ❑ $ Date USE OF � Q, EXISTING BLDG. DEMOL F-01&O' ignatui,A n Cw-- APPLICANT TEL. FINAL OWNER-BUILDEk DECLARATION (PRINT) NO. DATE �— I hereby affirm that I am exempt from the Contractor's License Lt Law for the following reason (Section 7031.5, Business and ADDRESS FINAL til li FEE Professions Code): PRESENT By hA BUILDING El 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work andt the structure is not intended or offered for sale(Section LOCALITY , , ` y 7044, Business and Professions Code.) MOVING TEL. R ) 1 E] m.e � t65,0119t Frtk� +�;ry: I,as owner of the property,axclusively contracting CONTRACTOR NO. I4J ! with licensed contractors to construct the project (Sec- ADDRESS U tion 7044, Business and Professions Code.) l CONSTRUCTION LENDING AGENCY SETQBACK YARD HWY TOTAPROPLINEFROM WIDTH �/1 I hereby affirm that there is a construction lending agency for [FRONTthe performance of the work for which this permit is issued .L. (Sec. 3097, Civ. C.). DE L. b�uLender's Name S LDMA Ref. # . Fee$ Permit Fee , � Lender's Address 1 certify that I have read this application and state that the Issuance Fee LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee LDMA Perm. # and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. 11-17—?j SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date