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Home My Public Portal About5724 ROSEMEAD BLVD_Building__ WORKERS'COMPENSATION DECLARATION hereby affirm that I have a certificate Policy NI-&-71 Compo f consent to self APPLICATION F OR S U I L D I N G PERMIT insure,or a certificate of Workers'Comp tion Insurance,or a certified co thereof Sec. 3800, La COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ;! BUILDING �7 � / ADDRESS /-27/ �+Z� �C+ Certified copy is filed wiItheuntybuilding inspec- BUILDINGADDRESS —.a &'a2 � „�� LOCALITYNEAREST ApplicanCITY ZIP CROSS ST. 12 CERTIFICATE OF EXEM ON FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE ESPECIAL hundred dollars ($100)or less.) TRACT BLOCK LOT NO. k Z- TEL // C' ,a�,r..oy � dI certify that in the performance of the work for which this OWNER N 4s•-�� ONS O permit is issued, I shall not employ any person in any mannerp Q' DISTRICT GROUP TYPE FIRE PRO ESSED BY, U so as to become subject to the Workers'Compensation Laws. ADDRESS Agi �-d �o �'h rJ CONST. _ `ZONE V Q �� Date Applicant CITY ZIP f1101C i STATISTICAL CLASSIFICATION CONDO. U NOTICE TO APPLICANT: If, after making this Certificate of ARCHIT CT OR TEL. LU Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL. UNITS H Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be .{ deemed revoked. CONTRACTOR N` O^i�fe BK. ` PG, v VALIDATION LICENSED CONTRACTORS DECLARATION LIC �+^ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ® V VALUATION (commencing with Section 7000)of Division 3 of the Business and LICy Professions Code, and my license is in full force and effect, CITY CLASS C- $ / SQ. FT. NO.OF NO.OF CHECK License Numb �tEa l� Lic.Class SIZE STORIES FAMILIES ONE Contractor Date DESCRIPTION OF WORK NEW $ 1 am exempt from the licensing requirements as I am a �� ADD F-1 licensed architect or a registered professional engineer ALTER FINAL . acting in my professional capacity (Section 7051, REPAIR DATE Business and Professions Code). USE OF FINAL EXISTING BLDG. DEMOL By Lic.or Reg.No. Date APPLICANT TEL. �+ OWNER-BUILDER DECLARATION (PRINT E tr ' NO a-�� I hereby affirm that I am exempt from the Contractor's License ADDRESS CX /� �� Law for the following reason (Section 7031.5, Business and 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 sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. 8 0 P I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ;.. 0 0 0 0 0 tion 7044, Business and Professions Code). rSIDE DDRESS REQUIRED TOTAL SETBACK FROM EXIST. 2 0 0CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH hIhereby affirm that there is a construction lending agency for FRONT o 0 o n G�(,X te performance of the work for which this permit is i;sued P L (Sec. 3097, Civ. C.). O _ 8 P.L. Lender's Name P.C. Fee S Permit FeeQ _ Lender's Address I certify that I have read this application and state that theE. Issuance Fee 4fl above information is correct. I agree to comply with all County Icl nvestigation Fee (� ordinances and State laws relating to building construction, Total Fee a a 3 and hereby authorize representatives of this County to enter u f above-mentio ed roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of A plic nt or Agent Dole es I ------ COIINTY OF LOS ANGELES'. O � � O WM. J. FOX, CHIEF ENGINEER. _ _ FOR APPLICANT TO FILL IN- FOR OFFICE USE ONLY DISTRICT NO. PLAN CK.NO. PERMIT NO. BUILDING = _ ADORE 69 I �, �a X47 _i4Rt�.A LOCALITY �+ - RECEIVED BY /DATE OF APPL.�J DAT•yISSUED NEA 'EST CROSS ST. L A is Mv e I BUILDING OWNER I--I .2 .f'_' �'C_E.,er-.R� L. ��£+A.lA-MAS ADDRESS Ct MAIL _s LOCALITY ADDRESS NEAREST //// �-- CROSS ST. .[fIV� 5 CITYmwmib- FIRE NO.OF TYPE GROUP ARCHITECT OR TEL. ZONE PLANS 2 = I�- �+ ENGINEER �e�a, PGL_I_IAj5NO. a�.hf� � BLDG. y+_ /' �+ ORD.NO. X.,',ADDRESS Z �? � 42A- lY 1 ,�° SETBACK LINE ) D y ��T r i APPROVED TEL. BY DATE CONTRACTOR NO. USE APPROVED ADDRESS '3 ZONE "�. BY DATE LEGAL DE CRIPTION LOT NO. m4 I BLOCK !�® 7 CORRECTIONS TRACT I I '�-. L `�. NO.OF BLDGS. SIZE OF LOT P.�� 1 ` fal NOW ON LOT hJ0Adk:' USEOFV NO.OF EXISTING BLD O •'S T . O JZ Fi".,i° I FAM FAMILILI ES � ROOMS :Mi4 DESCRIPTION OF WORK NEW ALTERATION ADDITION O REPAIR MOVING DEMOLISH p 5q.FT. NO.OF Z _SIZE �'�®fid ROOMS STORIES I r WALLROOF COVERING CO "C.�60Gt1! COVERING i:!f:E?&s q Q USE NEW BUILDING y� �(' Ab, ! L.- �-no re v.so ••p��6F,• 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE 19 CORRECT FOUNDATION: LOCATION INSPECTOR DATE _ AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS,MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION. f�00e �/ If FRAME: FIRESTOPS, SIGNATURE OF doff ' ,�� BRACING,BOLTS PERMITTEE LATH,INT.: AUTHORIZED AST LATH,EXT.: DBS-3 SOM SETS 7-47 $ 4 O may, P.C. ,3� PLASTER,INT.� �Q FEE �V _ PLASTER,EXT. VALUATION FINAL FEE C •'1 FA888Af81#80810-88 APPLICATION FOR BUILDING PE.RMII`f 1 COUNTY OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY ENGINEER ADDRESS BUILDING AND SAFETY DIVISION LOCALITY JOHN A. LAMBIE, COUNTY ENGINEER NEAREST CASSATT D.GRIFFIN,SUPT OF BUILDING CROSS ST. �. DISTRI NO. GROUP TYPE 2PROCE;SSED BY FOR APPLICANT TO FILL IN CONST. BUILDING _C— `7 STATISTICAL CLASSIFICATIONI SEWER AP ADDRESS L) pL. � BK PG CLASS.NO-� 3 nWELL.UNITSy1 LOT NO. BLOCK Mj �v a:, SHS NUMBE NO ' TRACT USE ZONE SPECIAL NO.OF.BLDGS CONDITIONS SIZE OF LOT I NOW ON LOT USE OF EXISTING BLDG. BUILDINGYARD HWY STREET NAME EXIST. SETBACK WIDTH OWNER FRONT MAIL P.L. ADDRESS Z SIDE TEL. P.L. CITY NO. INSPECTION RECORD ARCHITECT OR V TEL. ENGINEER NO. ADDRESS TEL. CONTRACTOR NO. p fP//ft; O / ADDRESS DESCRIPTION OF WORK -3 S �;�(l, s NEW ADD ALTER REPAIR DEMOLISH SQ.FT. NO.OF NO.OF E `- / tl III', SIZE STORIES FAMILIES USE OF +3 i-= v - 8U _/ Cr STRUCTURE _ r 14 N �S SIGNATURE OF APPLICANT pp APPROVALS DATE INSPECTOR'S SIGNATURE ADDRESS %S-7-mt-0 FOUNDATION: MATLOCATION CA ION VALUATION$ a� (a (, FRAME:FIRE STOPS, BRACING,BOLTS 0 o FURNACE:LOCATION. FEE $ I FEE $ ' I GAS VENT,DUCTS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- LATH.INT. PLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING BUILDING CONSTRUCTION. LATH,EXT. SIGNATUREOF . �p��.� �� HOUSE NUMBER COR- PERMITTEE W)0 f �•C� RECT AND POSTED ADDRESS ct'!�Qa73 I-�f.� FINAL CLYDE N. DIRLAM, PRINCIPAL TRUCTURAL EpGIIVNER PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. �P