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Home My Public Portal About5725 ROSEMEAD BLVD_Building__ It WORKERS' COMPENSATION DECLARATION t. I hereby affirm that I have a certificate of consent to self insure,,,pr a certificate of Workers' Compensation Insurance, P LIC:ATION FOR 3UILDING PERMIT or a certified copy thereof (Sec. 3800, , C,) / COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.1126-1-k Company o. BUILDING ❑ Certified copy is hereby furnished, TF�01RPLICANT TO FILL IN ; ADDREss❑ Certified copy is filed with the county building inspec- BUILDINGtion department. ADDRESSDate Applicant �, ��l� '• , CITY ZIP f LOCALITY — CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOTS ° NEAREST •. CROSS ST. COMPENSATION INSURANCE "ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE I PARCEL hundred dollars ($100)or less.) TEL. ` 5 OWNER ��yl ! NO. �"'t/�'O USE ZONE MAP I certify that in the performance of the work for which this //� NO. Qe o� SPECIAL �- permit is issued, I shall not employ any person in any manner ADDRESS r CONDITIONS CL soas to become subject to the Workers'Compensation Laws. O 4 CIN /� � ZIP U Date Applicant ,•ARCHITECT OR TEL. W NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP CTMOPNST. ZONE PROCESSED BY �O�- Exemption, you should become subject to the Workers' �, �nj' Z W Compensation provisions of the Labor Code, you must forth- ; ADDRESS , a with comply with such provisions or this permit shall be EL.. �/ c ATIS7ICAL CLASSIFICATION APT. CONDO. to deemed revoked. CONTRACTOR NO. ��f�7 Z_ LICENSED CONTRACTORS DECLARATION 7 ' •7 Gam' Q LIC.�y �j CLASS NO. 421 DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS G �/ r vNO.V ✓� SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,andel mly'license is in full force an ffect. ClN / CLASS BK PGVALIDATION License Numb r Jam+ Lic. Class SIE� }��G'• STORIIi4 FAMILIES CHECO EK �r ` VALUATION Contractor /"� to DESCRIPTION OF WORK /� ' NEW ❑ $ /0 H ❑1 am exempt under Sec. 11 ADD ❑ �V ALTER ❑ ., B.&P.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and 7 ADDRESS FINAL Professions Code): .:PRESENT By a,CCT a o4 BUILDING ❑ 1, as owner of the property, or my employees with ADDRESS qu,7c wages as their sole compensation,will do the work and ;I LOCALITY the structure is not intended or offered for sale(Section 1 7044, Business and Professions Code.) MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. A4r•4Ta4 with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code.) ADDRESS i, 3307 145.113 REQUIRED TOTAL SETBACK FROM EXIST. ITEMS CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. - s TOTAL 193.78 (Sec. 3097, Civ. C.). SIDE ' P.L. CHECK 193°73 Lender's Name • C y .•;' LDMA Ref. # CWGE .011 $ P.C. Fee$ , Permit Fee Lender's Address J ;t I certify that I ve read this application and state that the Issuance Fee / LDMA P/C# ® r. g P Y y g Q -�01 11I2,�/9� B above infor, at' n is correct.I a ree to com I with all Count Investi anon Fee arn dina e a State laws relating to building construction, Total Fee • 0 LDMA Perm.# (r3 1 hH 9 0 1L� d y Ythorize rep en tives of this County to enter Lei e above-m do erty for pection puToses, • SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Age/F Date APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY • WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS -72—S S I hereby affirm that I have a certificate of consent to self insure, BUILDING ADpBES G or a certificate of Workers'Compensation Insurance,or a certified C\ `CI ZIP copy thereof(Sec.3800,Lab.C.) CITY — LOCALITY Policy No. Company SIZE OF LOT 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 r CERTIFICATE OF EXEMPTION FROM WORKERS' OWA1 L COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundre S DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) I certifythat in the performa of the work r whic i it Y ZIP � Jam-Ub 6-2- is issued, I shall not empl any person in n ARCHITECT OR ENGINEER TEL\ NO.becom SUNS 'to the rkers'Com ns Ws. STATISTICAL CLASSIFICATION APT CO O Da' PH ant ADDRESS CLASS NO.—22-_ DWELL UNITS TO APPU If, a ter making this Certificate REQUIRED TOTAL SETBACK FROM EXIST xe tion, you should become subject to the Workers' CO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith N% FRONT comply with such provisions or this permit shall be deemed revoked. ADDR �• LIC.NO. G PL LICENSED CONTRACTORS DECLARATION J SIDE CITY LIC.G PL I hereby affirm that I am licensed underprovisions of Chapter 9 (commej.mw�elc_ ision 3 of the Business and S NO.OF STORIES NO.OF FAMILIES NEW ❑ SEWER MAP BK PG Professifull force and ec License CIaSS DESCRIPTI F WORK / ADD ❑ VALUATIONContr ctte Z zeezC— ALTER ❑ $ I am exempt under Sec. r REPAIR ❑ B.BP.C.for this reason DEMOL 11LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ Signature APPLICANT(PRINT) / EL qO. LDMA Perm# i ❑ 1-as owner of the property, or my employees with wages as , df ` �V7 /9 W Z their sole compensation, will do the work and the structure is A ESS �/r O :�Il CT. a (�•r , FINAL DATE Q �� "�,' ' not intended or offered for sale (Section 7044, Business and C �` 4, ,c•s Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARK;;US MATERIAL ��)�{�r J i ( 1 C'fa� ❑ I, as owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE s J.I L-I 15 Y, Y AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY _ licensed contractors to construct the project (Section 7044, 2 Business and Professions Code.) YES❑ No❑ TOTAL a_r� m •a----� WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING I C 89.25•�F=E OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH �•i�EC 89 o 2 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES CHANGE e -I I hereby affirm that there is a construction lending agency for YES 11NO❑ CM the performance of the work for which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING a 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. -,!-F! N TITLE 2,CHAPTER 2 20 SECTIONS 2.20.100 THROUGH 2 20.140 CONCERNING HAZARDOUS 00130—j 1313 i //12.r Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. 00 Lender's Address SS�38 N1!�. �• OWNER OR AGENT i.F•�iil {-li I i li c I cert' I have read this ap n an tate u r penalty c P.C.FEE PERMIT FEE c Per t at the above in 1 is co ct.I a e to comply f_ with all c my ordina s State ws r Ing to building �O 4 constructs h o• e resent ves ofXthiCvnty ISSUANCE FEE nter th ve- ntion rope or inspectie CD INVESTIGATION FEE TOTAL FEE - �7S/2- I` gno�uv a Mcumm>Aip,ry Om SEE REVERSE FOR EXPLANATORY LANGUAGE R APPLICATION FOR BUILDING PERMIT � COUNTY OF LOS ANGELES BUILDING AND SAFETY a WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS / BUIL SS � � /[-G'.[.sCi "'mer.• I hereby affirm that I have a certificated consent to self insure, 1/t ��_ �/� LVD .or a certificate of Workers'Compensation Insuranc or a certified CITY✓,�! A PL L�, ZIP I •�' copy thereof(Seec.3800 Lab.C.) N -180 Policy No.Z � o Compa LOCALITY/ /• //— SIZ OF LOT NO.OF BLDGS.NOW ON LOT G7�L �� ✓G ❑ Certified copy is hereby furnished. J11iEST CROs tT. ❑ Ce ified copy is filed with the county building inspection TRACT BLOCK LOT NO. 7 i rN v (3��-� dartmen� �� ASSESSOR MAP BOOK PAGE USE ZONE MAP t�0. ✓ Date r� Applicant PARCEL SPECIAL CONDITIONS /f o P V x CERTIFICATE OF EXEMPTION FROM WORKERS' o " f b�lv , �- - �; 0 42�� (f,/ (J COMPENSATION INSURANCE [[p�1pR�Tii ! `�''�6 L/ WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred Asq V '�,R 'jf� .� , dollars($100)or less.) G/W !4tl V!a° DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY CITY ZIP J I certify that in the performance of the work for which this permit Q. �Cp/��9 is issued, I shall not employ any person in any manner so as to AR ITC �R IAEA NO. -9 �� become subject to the Workers'Compensation Laws. U I�/A /�i�l�f L�' ^tJ STATISTICAL CLASSIFICATION APT CONDO Date Applicant D Z.��4f0{' fx�y+'(4��(�' V J�- O CLASS NO. � DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate Of r 1 ` W"'—� 'V REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject t0 the Workers C �Tf ^„f) t -a��/„e J„ SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith 1�if(,�L [y�f� FRONT _T comply with such provisions or this permit shall be deemed revoked. ADDRES 41,4 � t7 w .N P L bl LICENSED CONTRACTORS DECLARATION `S�Pi SIDE a, /t. T LIC.CLASS P L �-V ,Ib I hereby affirm that I am licensed underprovisions of Chapter 9 (-,,{ _L.`• y` �_?�� (commencing with Section 7000)of Division 3 of the Business and Y F�IZE NO.OF STORIES NO.OF FAMILIES SEWER MAP - Professions Code, m IIWse is in full force and effect. Y ((do I NEW 11 BK PG L'-;7!,i - v License Number LIC.Class 0?9 DESCRI.1 ePTION OF RK ADD ❑ VALU TION 7'c"tT. I =p,,r•.r dF j n Contractol� te -p�q 1 ALTER �v f:�`I_I'. " o i'-LU E REPAIR ❑ t' v� ❑ I am exempt under Sec. $ 1:Hti 1.3t B.BP.C.for this reason DEMOL ❑ LDMA P/C# Date: US BLDG. URM ❑ SignatureNip AP T PRIN ) TE N9. LDMA Perm# ❑ I,as owner of theproperty, or employees �y Z my with wages as S' O their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and a&- �L' FINAL DATE Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL %f —I� + i OR A MIXTURE CONDONING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J i 3 I ENS ❑ 1, as owner of the property, am exclusively contracting With AMOUNTS SPECIFI ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project (Section 7044, YES❑ No TOTAL l j AL "H-��I� � 52Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING 1�y1"1�1_M• .:sl I� OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _ CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR ; �F�I q .�( GUIDELINES. f ;•r. I hereby affirm that there is a construction lending agency for "-''- YES ANO N the performance of the work for which this permit is issued(Sec.p1 IH DO MATERULLSINFORMATIONGUIDE AND THE SCAOMD PERMITTING 3097,CIV.C.) E REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. rN E S 2 20.100 THROUGH 2 20.140 CONCERNING HAZARDOUS !:I,I"Ij_�[_,•� 4./ y '�4 Lender's Name MAD IT FROM THE SCAOMD. Lender's Address 54115 4 , O E R j. ! ))•� a f}� o I certify that I have read this application and state under penalty of perjury that ove information is wrrect. agree to comply P.C.FEE 21 �� PERMIT FEE �� j a N with all co y ina and to la lating to building construct' , a hereby thor re fives f this County ISSUANCE FEE . to ente po a above- ntio pe or in ectioon ppuur )us'eS. Q0 / % INVESTIGATION FEE TOTAL FEE .S ome g SEE REVERSE FOR EXPLANATORY LANGUAGE COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SIGN BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0301100031 PHONE: (626) 285-0488 EXT: LEGAL ID: NUMBER OF SIGNS: BUI LDING ADDRESS: ON FILE SIGN DESCRIPTION: NEON SIGN ON ARCH 5725 ROSEMEAD BL TEMP CA 91780 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LAS TUNAS 5397-012-043 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY E S LDG USE: S ED O --PROCESSED BY: EXPIRES 0 : ROADHOUSE COFFEE EXIST OCC GRP: 01/17/03 JK 01/12/04 OWNER: TEL. N0: BLDGS. NOM ON LOT: VALUATION: F ALI�ATE FINA Y: CODE: 3AALOAAC INVESTMENT - 2,435 SAN DIEGO, CA9211137ES F A I D DESCRIPTION OF WORK EXPOSED NEON SIGN "YOUR NEIGHBORHOOD COFFEE SHOP SINCE 9411 FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: APPLICANTi NO: SANCHEZ (626) 401-9282- AA BLDG PERMIT ISSUANCE 27.75 2216 MERCED AVENUE AC STRONG MOTION RESID 2435.00 VAL 0.50 SPECIAL CONDITIONS: SOUTH EL MONTE AX BUILDING REV.IEW:!FEE-77 ., 54.20 D2 PERMIT W/0-EN�+C�---:_24`5;•00 VAL 99.00 Z TQT.A �F ES, 181.45 CONTRACTOR: TEL. NO: �l�J \,� APPROVALS DATE INSPECTOR SIGNATURE 5SIGNS 98451/2ALBURTIS AVE (562) 801- 033- 9845 ` �� LOCATION SETBACKS SANTA FE SPRINGS CA 90670 569180 C45 SOILS ENGINEER APPROVAL ARCHITECT OR ENGINEER: TEL. NO: ' ' � r �---� FOUNDATION/TRENCH FORMS LIC. N0: _ I I ,_, `1 SUPPORT STRUCTURE P NO: SEWER MAP BOOK: PAGE: FIRE ZONE: C Pj:=y I f r; . C ALJ NO. OF FAMILIES: DWELLING UNITS: PTC D: STAT CLASS::- No ASS;:NO 20 'V-\ 711 SCHOOL WITHIN HAZARDOUS �,�AIR QUALITY: 1000 FEET MATERIALS ��• -� j I NO NO NO � \ 1' r� r-i; '-�p j ;�N C t � L3 �0 3 - iuoT' i.-ss'r�CC'ta - REPORT ID: DPR261 ROUTE TO: BS0508