HomeMy Public PortalAbout5749 ROSEMEAD BLVD_Building__ WORI` _'OMPENSATION DECLARATION
hereby a ce I have certificate of consent to self P P L I�`�r� o r I®N F® BUILDING R �
insure, or a certifilate of Workers' Compensation Insurance,
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 DRESS
El
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
CITY ®_ / C 421 r,
Date Applicant ZIP ?LOCALITY
NO. OF BLDGS. iv+.NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT ,r 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 ,p7N^�,aC 1 Np, P USE ZONE MAP
I certify that in the performance of the work for which this NO.
SPECIAL >_
permit is issued, I shall not employ any person in any manner ADDRESS b CONDITIONS a
so as to become subject to the Workers'Compensation Laws. O
CIN ZIP U
Date Applicant ARCHITECT 9IRimTEL. DISTRICT ;-OU
P TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE ~-
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS .Q� a
with comply with such provisions or this permit shall be z
p y p p � � TEL. � STATISTICAL CLASSIFI TION APT. CON O. Z
deemed revoked. , CONTRACTOR 6-V F NO. s _
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. ELL. U S
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS q 1-2 It`'NO. �� :
(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. CLASS CL 0 BK _ VALIDATION
L SQ. OF NO. CHECK
License Number Lic. Class Cl O SIZE STORI S FAMILIES ONE ' A
If`f�� � `a VALUATION _ h
Contractor -7,
, ate GJ DESC ION O NEW
ADD ❑
ElI am exempt under Sec. Lr� � / �-f '1•e�E< �� .� �•!_!iL
'.Y p-p y_
BAP.C. for this reason ALTER 10REPAIR ❑ $ ® �' deo, - 186 m 47
Date:
USE OF - ! ° •�
EXISTING BLDG. DEMOL ❑ �}!; f
Signature APPLICANT TEL / ` ` r- �`'-I�`°�'
OWNER-BUILDER DECLARATION (PRINT) /�� NO. ��a�it DATEFINAL �q � � °iI
I hereby affirm that I am exempt from the Contractor's License 1
Law for the following reason (Section 7031.5, Business and ADDRESS OZ /�LL��/ ✓1 FINAL � ~ r
Professions Code): PRESENT By }; �i�i E-I ll�i] 1 J
BUILDING '
❑ I, as owner of theproperty, or m employees with
YADDRESS dd t r•_�L;` 1 i-ltit
wages as their sole compensation,will do the work and ? i( (*�
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL. �� .G�� TOT I AL 9 1 1 ®2}
❑ I,as owner of the property,am exclusive) contractingCONTRACTOR NO. _ -
with licensed contractors to construct the project (Sec- ADDRESS ep CHECK
��1°=''
tion 7044, Business and Professions Code.) i� 1N�t��3c
CONSTRUCTION LENDING AGENCY SETQBACK YARD HWY TOTAL SETBACK
iINEFROM 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• t f tr fU;
(Sec. 3097, Civ. C.). SIDE 0�)�-i-`-0tl01
P.L.
Lender's Name 7734 1 Al"11 "P4
�� LDMA Ref. #
P.C. Fee$ ro Permit Fee i' r
Lender's Address
I certify that I have read this application and state that the Issuance Fee LDMA P/C#
' Investigation Fee
,rX 12A
above information is correct. I agree to comply with all County 9
ordinances and State laws relating to building construction, Total Fee tZ ® e LDMA Perm. #
( and hereby uthoriFOR
ti this County to enter
upon th r inspection ses.
i Y. , f,� �/ SEE REVERSE FOR EXPLANATORY LANGUAGE
§U96tuFe of App scant or Agent Date
Wq i COMPENSATION DECLARATION
I
I hereby afi at I have riYcertificate of consent to self ® P P L Imss�`T'®N R BUILDING PERM....
insure, or a cercate of Workers'Compensation Insurance, �®
or a certified copy thereof Sec. 38 ,1,.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. 3�� genp�ny
❑/Certifi c4;& Fere6y furnished. �r '�I FOR APPLI NT TO FILL IN Ao�RIE�ss��
D Certified copy is filed with the county building inspec- BUILDING..qr
tion department. �.O ADDRESS
�f�%
Dated-2L Applicant - "L CITY G ZIP LOCALITY
OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT OW ON LOT CROSS ST.
COMPENSATION INSURANCEASSESSOR �e
(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.) �j� tATEL.
OWNER L�""` ANO. _ USE ZON
/a D E NO.
-/-/-,7�
I certify that in the performance of the work for which this
SPECIAL >_
permit is issued, I shall not employ any person in any manner ADDRESS G u CONDITIONS o_
so as to become-subject to the Workers'Compensation Laws. O
CITY &/p��GIP U
Date Applicant ARCHITECT O TEL. ,�/ ` DISTRICT GROUP TY FIRE PROCESSED BY aC
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER , LI�• NO. �9O
Exemption, you should become subject to the Workers' `' I ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS ��� /Yl� '�.�� -,�-' nw.
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. Z
LICENSED CONTRACTORS DECLARATION �j LIC. CLASS NO. DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. ,FQ/J06
(commencing with Section 7000)of Division 3 of the Business
LIC. SEWER MAP
and Professions Code,and my license is in full force a effect. CLASS BK. PG. VALIDATION
����d
i1 pr S FT. NO.OF NO.OF CHECK
License Number Lic. Class SIZE STORIES FAMILIES ONE
�/' VALUATION
Contractor ��`-'l m ate � � DESCRIPTION OF WORK NEW $
❑I am exempt under Sec. ;5 ADD A10.1 ,
ALTER ❑
BAP.C. for this reason r, a REPAIR ❑ $
Date: USE OF
� #'EXISTING BLDG. DEMOL ElQ!Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION (PRINT) NO. DATE !!I!z
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and .ADDRESS FINAL
Professions Code): PRESENT BY -
r, _
❑ BUILDING z
�.�.} °I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and _'137
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL. ® 1 I T M DO
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- I}_})(-1L ,� m + +
ADDRESS
tion 7044, Business and Professions Code.) �-
REQUIRED TOTAL SETBACK FROM EXIST. AHECK
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH a
I `H;;i hereby affirm that there is a construction lending agency for FRONT GE
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
_ ,,.�
LIQ}0-00 l�1•. 4/ 4/9i
Lender's Name P.L. �-p� a
11✓(i' d Ref. # .yt}� 1 N
P.C. Fee$ Permit Fee F 111 i I t 1
Lender's Address �>
I certify that I have read this application and state that the Issuance Fee rJQ LDMA P/C#
above information is correc agree to comply with all County Investigation Fee qp
3 ordinances and State la P relating to building construction, Total Fee " LDMA Perm. #
( and here orize presentatives of this County to enter
@$ upon a above-m coned operty for inspection purpos s.
r Cf� SEE REVERSE FOR EXPLANATORY LANGUAGE
vvv Signat_; pylic or A nt to /
WO COMPENSATION DECLARATION
hereby off! it I have certificate of consent to self A P P L I GhT I®N FOR BUILDING P E RM I� __
insure, or a certificate of Workers, Compensation Insurance,
or a certifi c$y re 5800, b. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
1 .
Policy m ny ;r
BUILDING l//Z
�❑ tified copy is hereby furnished.
2 -9�" "` FOR APPLICANT TO FILL IN ADDRESS
L Certified copy is filed with the county buil Ing i - ILDING
tion epart ent. DDRESS � 7 G
r
GayDate Applica , CI • % L/r/ ZIP :~LOCALITY V
NO.OF BLD NEAREST
AT
CERT ICA OF EX ON FROM WO ERS' • SIZE OF LOT NOW ON LOTT .CROSS ST. 1�
o COMPENSN 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 - WODO Np•Fa USE ZONE MAP
I certify that in the performance of the work for which this NO.
pp� SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS hl►C� CONDITIONS
so as to become subject to the Workers'Compensation Laws. .r O
CITY i UMAAKZIP
Date Applicant ARCHrrECT ORoe
DISTRICT GROUP TYPE FIRE PROCESSED BY Q
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST, ZONE 0
Exemption, you should become subject to the Workers' L/08' ?
Compensation provisions of the Labor Code, you must forth- ADDRESS o/' ✓ a
with comply with such provisions or this permit shall beCONRACTOR % p -. ATISTICAL CLASSIFCIUION APT. CONDO. Z
deemed revoked. —
LICENSED CONTRACTORS DECLARATION IC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O.
(commencing with Section 7000)of Division 3 of the Business LIC, / SEWER MAP
and Professions Code,and m license is in full force and effect. CITY CLASS Ci VALIDATION
2�� 3� Lic. Class SQ' FT.- 00. OF' O.OF CHECK BK. PG.
License Number. SIZE STORIES FAMILIES ONE Y
f'_ �/ VALUATION
Contractor ' wUa} r � q1 DESCRIPTION OF WORK NEW µ, $ ��
❑I am a empt under Sec. 1 ADD ❑ ?_ �! ►
v ALTER ❑ $
B.&P.C. for this reason
USE OF REPAIR ❑ `)`
Date: EXISTING BLDG. DEMOL ❑
Signature APPLICANT PRINT TEL. FINAL
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and >ADDRESS 1i7�1 44
FINAL
nI s
Professions Code): PRESENT FI l�Z:=•t
BUILDING
❑ I, as owner of the property, or my employees with =ADDRESS F LIJ� _7
wages as their sole compensation,will do the work and _�=s o 46
the structure is not intended or offered for sale(Section LOCALITY I;
7044, Business and Professions Code.) , MOVING TEL. Poo &
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. ACL 1,;
with licensed contractors to construct the project (Sec- ADDRESS .' -
tion 7044, Business and Professions-Code.) ' ti� t1% it5,_,_,
REQUIRED TOTAL SETBACK FROM EXIST. s-
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH - t i l`l'
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• I I j AL 164:3 m 06
(Sec. 3097, Civ. C.). SIDE �•,
P.I-.-- =HECa Zr 1�,{1
Lender's Name ;�I�„j���
S n LDMA Ref. # • t tri GE a FIT,
P.C. Fee$ Permit Fee OL '
Lender's Address ,
1 certify that I have read this application and state that the Issuance Fee LDMA P/C#
3 above information is correct. I agree to comply with all County Investigation Fee Sir Y1
ordinances State laws relating to building construction, �03
Total Fee ed• LDMA Perm. # p
and here thor' a rep sent of this unty t enter W75 ' ty Tie iE�
° upo o e- do d pr t for ins ction et
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Appli t or Agent Do
WO COMPENSATION DECLARATION W X "
I hereby affii it I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, A P D LT R
a— ® �®N FOR BUILDING P E S°a .,
or a certified copy thereoygf�Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poli No.?, �S Fompany n�'T _�vh/1J BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN
ADDRESS
❑ Certified copy is filed with the c my building inspec- BUILDING 7L �'��
tion department. ADDRESS
( CITY IE d ZIP LOCALITY
Date Applicant NO.OF BLDGS. u NEAREST
OF
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. �,':• a
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.) T f?xX NO. USE ZONE MAP .
OWNER NO. 3 i._V(+
I certify that in the performance of the work for which this +J SPECIAL
permit is issued, I shall not employ any person in any manner ; ADDRESS 7 � i?Up p 'O� +r )
CONDITIONS I-i 1 4• ' z # v21
so as to become subject to the Wor s'Compensation Laws. —
�i CITY����/!� 04 z I P 01701 CHECK,
s_
Date �� `/Applicant I i ARCHITECT OR TEL. DISTRICT ;GROUP TYPE FIREr• PROCESSED BY
NOTICE TO AP LICANT: If, after making this ertificate of ENGINEER NO. CONST. ZOExemption, you should become subject to the Workers' n '/Compensation provisions of the Labor Code, you must forth- ADDRESS v� 'p2 V N
with comply with such provisions or this permit shall be TEL STATISTICAL CLA =-,i:z
�O DO. .
deemed revoked. CONTRACTOR�d3✓- G N I� L �i+' Z-
ULIC. CLASS NO. DWELL. UNITSLICENSED CONTRACTORS DECLARATION /
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS (p/ �(/)Ts4 NQc1ISa 2
(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.� Agw/ /!qv CLASS�� BK PG VALIDATION
License Number_c3T31 (� NO. OF NO. OF CHECK -
Lic. Class SIZE STORIES FAMILIES ONE
/� VALUATION
Contractor,/ LY I Date ,v `° DESCRIPTION OF WORK 40 �' �/� NEW $ %/
ADD ❑ ►
❑I am exempt under Sec. di 1 62 C$y
ALTER ❑ .
BAP.C. for this reason ���+r — REPAIR ❑ ; $
Date: USE OF
Iol EXISTING BLDG. DEMOL ❑
APPLICANT
Signature (PRINT)1&7�C/9/� NO. 91el.1 FINAL
OWNER-BUILDER DE RATION //�� QQ DATE 0"�
I hereby affirm that I am exempt from the Contractor's License ADDRESSlarJ�/�`7� �� T/g
Law for the following reason (Section 7031.5, Business and FINAL =
Professions Code): PRESENT By 4 _i °M
❑ I, as owner of the property, or m employees with BUILDING
P P Y� YADDRESS
wages as their sole compensation,will do the work and u IJ` ,''T, LL
the structure is not intended or offered for sale(Section LOCALITY _—DES 7044, Business and Professions Code.) MOVING TEL. DE•=
3!
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec-
_ 13
tion 7044, Business and Professions Code.) ADDRESS CHECK
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH `_;HANIG.;= i•�
I hereby affirm that there is a construction lending agency for FRONT •Jt.
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L. _ tt=ij 7/,
Lender's Name LDMA Ref. # 'i__tAli
P.C. Fee$ 17 r 1,4 Permit Fee
y F 11iJ
Lender's Address ,
I 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 / e�
yordinances and State laws relating to building construction, Total Fee [G' c LDMA Perm. #
( and her y authorize representatives of this County to enter
up above- entioned property for inspection purposes.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Appl' nt or Agent Da e
WOI COMPENSATION DECLARATION T ,
insure, oroa certificate of Wo.ke s'tificate Compensat o ®®
of consent'to self
Compensation Insurance, B►`®Y P L I C ® ■ I®N FOR BUIL®M PERM®, B
or a certified copy thereof(Sec. 38b. c. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No v`99Companya�r
PyA y., FOR APPLICANT TO FILL IN BUILDING
❑ .Ce�tf�°i co is eb furnished. //-�/r/ ADDRESS
❑ Certified copy is filed with thercounty building inspec-• BUILDING
tion department. �! ADDRESS /
Date Applicant t�/ ^ � CIN ZIP LOCALITY
' O. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE 1 ASSESSOR ��
.(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE�/-9- PARC
hundred dollars ($100)or less.) TEL USE ZONE MAP'
:a OWNER NO. [o ' NO.
I certify that in the performance of the work for which thisSP
,/
permit is issued,•I,shall-not employ any person-in any manner ( ADDRESS o iii+ "��o� .,; CONDITIONS X707 4IL
so as to-become subject to the Workers'Compensation Laws. e�, O
CITY C-•f2lp � ! V
Date Applicant ARCHITECT TEL. /
ae
-NOTICE TO APPLICANT: If, after making•'this Certificate of ENGINEER - Loci NO. _ DISTRICT GROUP TYPE FIRE PROCESSED BY - O
Exemption, you should become subject to the Workers' / CONSTf./ ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS `'
with comply with such provisions or this permit shall be E STATISTICAL CLASSIFICATION APT CONDO. N
deemed revoked. CONTRACTOR re # (` i Z
LIC. s. CLASS N0.�DWELL. UNITS
LICENSED CONTRACTORS DECLARATION qp
',ADD
LIC I�
I hereby affirm that'l am licensed under provisions of Chapter 9 ? SEWER MAP
(commencing with Section 7000)of Division 3 of the Business ���� ] T f M.I
and Professions Code d my license is in full force and effect. CLASS 4;' BK. PG. VALIDATION
SQ. FT. SNO.TORIES
IE FA OF CHECK €F I � 1749.9 i
License Number �� Lic. Class � SIZE STORIES FAMILIES ONE ;.
T. VALUATION CHECK .E{�'3=`��!"�
Contractor//C� i�^�!�ete ��r ���� DESCRIPTION OF WORK NEW ❑ $ J0401040. p p -
A El HGE V13
PO- CHA
❑I am exempt under Sec. '
ALTER ❑
B.BP.C. for this reason �,/• REPAIR ❑ '} $ i
Date: /0� USE OF
EXISTING BLDG. DEMOL ❑ F,t
Signature APPLICANT TEL. FINAL ' { i t Y IC
OWNER-BUILDER DECLARATION (PRINT) NO. g
DATE L Q`- —a.
I hereby affirm That•I am exempt from the Contractor's License ;�ADDRESS � � •
Law for the following reason (Section 7031.5, Business dnd FINAL
Professions Code): s`PRESENT By
BUILDING
I, as owner of the property, or my employees with ADDRESS r.
wages as their sole-compensation;will do the work and LOCALITY
the structure is not intended or offered for sale(Section
—/7044, Business and Professions Code.) MOVING TEL. (y; ;;
I,as owner of the property,am exclusively contracting CONTRACTOR NO. _�� r,•
with licensed contractors to construct the project (Sec- ADDRESS "
SL
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is.a construction•lending agency for FRONT T);i HL. 2+• • _='
the performance of the work for which this permit Is issued P•L• y {;C. -n
(Sec. 3097, Civ.,C.). SIDE CHECK .42 i■.a
P.L.' r r*
CHANGE
Lender's Name LDpMA Ref. #
8 P.C..Fee$ • Permit Fee
Lender's Address _
' I certify that I have read this application and state that the Issuance Fee /3 - LDMA P/C# ® Ia"%1 "'()Lil 7111x;'
above information is correct.I agree to comply with all County Invedtigation Fee _ ,r ,9:47
ordinances and Stat ws relating to building construction, t'. Total Fe LDMA Perm. # r916 1 All °
and hereby�outhoriz re resentatives of this County to enter
upon th ove=me do d property for inspection urp §es.
o O�� 'SEE REVERSE FOR EXPLANATORY LANGUAGE
Slgnatu tf Applicant or Agent Date .
AMU
RMN FOR 13UILDINQ PEW,c� r
COUNTY 00`-a_a ANGELES BUILDING AND SAFETY
WORKERS COMPENSATION DECLARATION
FOR APPLICANT TO FILL IN BUILDING ADDRESS-
t
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS
or a certificate of Workers'Compensation Insurance,or a certified S Q•OSM� 13L a/T7• 5 7
copy there0 (Sec.380 ,Lab.C.) � OITY�- N ZIP 05�I�� 15L\/O.
e �rG' "" 1 �L E C) , 1 LOCALITY r- I
,P,oliiccy. Q r S COmpan 0 c SIZE OF LOT NO.OF BLDG§.NOW ON LOT NEAREST CROSS ST 41-`�� G 1 I
LdJ Certifi copy is hereby umished. ���/I ?j?_ 12 S•f L,6,S TMJ rye
TRACT BLOCK LOT NO. USE ZONE MAP NO.
❑ Certified copy is filed with the county building inspection �JO N 26�J
department. � h � 3<v'L'3 102, IDS tTL
Date ael Applicant Pe ASSESSOR MAP BOOK EC)IJ.Z PARC I I J n
7 �• L SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OC} 1P4-J?1Of l IJF_V'EL..f7PM• TEL
O. YES NO
COMPENSATION INSURANCE 213 37 WITHIN 1000 FT OF SCHOOL?
ADDRESS
(This section need not be completed if the permit is for one hundred 206) 06a'.0 G�Te 1771, 1-Y
L-DO R- DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY
dollars($100)or less.) CITY ZIP
I certify that in the performance of the work for which this permit L-0N611 -F—L�._� H , �• 0 Q'L �,0g �-2 3 �
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. T.W, LJWMA-t4 A.SS Q C. STATISTICAL CLASSIFICATION APT CONDO
I
Date Applicant ADDRESS CLASS NO.- C92 DWELL UNITS
NOTICE TO APPLICANT: If, after making this Certificate of Vao ISIuYS 13L✓D. VA-tJ Wuys REQUIRED TOTALSE- t ROM EXIST
Exemption, you should become subject t0 the Workers' CO .�� P/L�CTOR TEL NO. SET BACK YARD HWY PROP LINE + ^;- WIDTH
Compensation provisions of the Labor Code,you must forthwith i FROG
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIQ..NOPL
Cc �� � ��Q CL, PL SIDE two O i
?.+Y.�P�.6ZZ fry/ G� I�-y_�-•}.� L:i i
LICENSED CONTRACTORS DECLARATION I Llc.c P L J;NE�k.K y a 4k
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP L, r L1
(Commencing with Section 7000)of DIVISIQn 3 of the Business and SO.FT E NO. STORES NO. FAMILIESCHANGE
Professions Code,and my license is in full force and ct. 2S 1 NEW ❑ BK PG
License Number dALib Class
DESCRIPTION OF WORK ADD ❑ VALUATIOPA ® �eR. i /1LLI
CAI 1 I IJIiIY�I i�I}�JIL �ii i�
Contractor Date �� ` ALTER ❑ _I 1
❑ I am exempt under Sec. REPAIR 13f
B.BP.C.for this reason / DEMOL ❑ LDMA P/C a
Date: USE OF EXISTING BLDG. UREA ❑
Signature APPLICANT(PAIN') TELO. LDMA Perm M
❑ I,as owner of the property, or my employees with wages as W . LA` MTI x.55 oc-• 11619117-9,15Z 0
their sole compensation,will do the work and the structure Is ADDRESS 1
not intended or offered for sale (Section 7044, Business and AI.I IV t1 S L_V®, VAIJ q! S FINALDATf l 1 ® ..
Professions)Ode.) WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANTHANDLEA HAZARDOUS MATERIAL l y``
roe g OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EOUAL TO OR GREATER THAN
I, as owner of the
p p rty, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE4 FINAL B
licensed contractors to construct the project (Section 7044, yrs❑ NO❑
Business and Professions Code.)
WILL THE INTENDED USE THE BUILDING BY THE APPLICANT FUTURE BUILDING /n�
OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH �f
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST
FORGUIDELINES. ��/•/ l �
1 hereby affirm that there is a construction lending agency for yrs❑ No[3
the performance of the work for which this permit is issued(Sec. �<f 9Q�•/oZ f-�p /,
I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD / U"9 •1
3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES
Lender's NamCOUNTY CODE,TITLE 2,CHAPTER 220 SECTIONS 2.2CL100THROUGH 220.140 CONCERNING
e HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
IL Lender's Address oW,maR�cwrjf�, p/
o I certify th t I have read this 9 plication and state that the abov� RC.FEE D PERMIT FEE ��
informs is correct. I e ree to comply with all count GL
ordin and State laws relating to building construction,and 02-3
here uthorize representatives of this County to enter upon ISSUANCE FEE /�. D ��z y
th mention or inspection purposes. I
�• m —1/-0/ 1 INVESTIGATION FEE TOTAL F of AMftM
�j Q crd 0
�� SEE REVERSE FOR EXPLANATORY LANGUAGE '
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ti. �Ull DING PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS TENANT-tMPROVEMENT f
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA BL 0508 9802170001
PHONE: (818) 285-0488 EXT:
D: NO. OF CONST NEW
ON FILE SQ. FT STORIES TYPE OCCUP GROUP 5749 ROSEMEAD BL.~
STRUCTURE: 0 1 VN B -ZMP-CA-9.1-780
ASSESSOR N OR TION NU BE : NEAREST CROSS STREET: ROSEMEAD
5397-012-043 THOMAS PAGE: GRID: LOCA ITY: TEMPLE CITY
TENANT: EXIST BLDG USE. COMME USE 0 E: ISSUED ON: PROCESSED BY: EXPIRES ON:
T.J. MAXX EXIST OCC GRP: B 02/17/98 UT 02/17/99
OWNER: TEL. NO: BLDGS. NOW ON LOT: VALUATION: FINAL DATE FINA B CODE:
CALAC INVESTMENT - 70,000 �J�
3709 6
SAN DIEGO, CA9211137 fEES PAID AF-5 LC
REVAMP CENTER SOFFIT AND LIGHT-
APPLICANT:
IGH
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT. i...
A PLI N EL. NO:
J. K. BAKER CONSTRUCTION (408) 882-0199- AA BLDG PERMIT ISSUANCE 27.75
2175 STONE AAVE. #11 AC STRONG MOTION RESID 100000.00 VAL 10.00 SPECIAL CONDITIONS:
SAN JOSE, CA AX BUILDING REVIEW FEE 54.70
D2 PERMIT W/O EN-HC 100000.00 VAL TOTAL FEES 1,1,198.39105.94
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
JK BAKER CONSTRUCTION (408) 882-0199-
2175 STONE AVE. #11 LIC. NO LOCATION AND SETBACKS
SAN JOSE, CA 95125 636446 B
SOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER: TEL. N0: FOUNDATION/TR5NCH FORMS
LIC. NO: SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE- CMP: UNDERFLOOR INSULATION
3 04
FLOOR SHEATHING
0. OF FAMILIES: DWELLING UNITS: APT CO D: STAT CLASS:
NO 22 ROOF SHEATHING
i
SCHOOL WITHIN SHEAR_-PANELS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO FRAME INSPECTION
FIRE 5 RIN L HANG RS
INSULATION/WEATHER STRIP
INTERIOR LAT
EXTERIOR LATH
RAM OOR ASSM.
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
-BAR CEILINGS !�
LOT DRAINAGE `
REPORT ID: DPR261 ROUTE TO: BS0508
' COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS TENANT IMPROVEMENT
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1105030025
PHONE: (626) 285-0488 EXT:
LEGAL ID: NO. OF CONST NEW BUILDING ADDRESS:
ON FILE SQ. £T STORIES TYPE OCCUP GROUP 5749 ROSEMEAD BL 1
ISTRUCTURE: 775 1 V-B B I TEMP CA 91780
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LAS TUNAS
15397-012-043 1 1 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY, Ci
TENANT: EXIST BLDG USE: COMME USE ZONE: ISSUED ON: PROCESSED BY:
ITJ MAXX EXIST OCC GRP: B 106/07/11 SR
OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: IF AL D E FIN CODE:
TJX COMPANIES INC. (508) 390-5180- I 35,000
1770 COCHITUATE RD. ,I I ,� / I
1
IFRAMINGHAM, MA 01701 FEES PAID IDESCRIPT ON OF WORK
MINOR TENANT IMPROVEMENT TO EXISTING DRESSING ROOMS AND
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1COSMETIC UPDATE OF STORE
[APPLICANT: TEL. NO: I
MICHAEL HAM (858) 792-6855- IA1 PLANCHECK W/EN-HC 35000.00 VAL 587.70
113025 CALLCOTT WAY IAA BLDG PERMIT ISSUANCE 27.80 ISPECIAL CONDITIONS:
SAN DIEGO, CA 92130 'IAB STATE GREEN BLDG FEE 35000.00 VAL 2.00
IIA2 PERMIT W/ENERGY-HC 35000.00 VAL 691.50
TOTAL FEES 1,309.00
CONTRACTOR: TEL. NO: ]APPROVALS DATE INSPECTOR SIGNATURE
DEL MAR BUILDERS (858) 792-6855-
113025 CALLCOTT WAY LIC. NO ILOCATION AND SETBACKS
ISAN DIEGO, CA 92130-1329 594663 I
1SOILS ENGINEER APPROVAL
]ARCHITECT OR ENGINEER: TEL. NO: IFOUNDATION/TRENCH FORMS I I I
SCOTT GIBSON ARCH (530) 343-7447- I I I
12540 ZANELLA WAY STE 60 LIC. NO: (SLAB/UNDER FLOOR
ICHICO, CA 95928 NONE
1RAISED FLOOR FRAMING
(MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:( :UNDERFLOOR INSULATION I I I
I I
I
1-1
1 3 041 1FLOOR SHEATHING
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I I I I
0 NO 22 I IROOF SHEATHING
I I I
SCHOOL WITHIN HAZARDOUS I ISHEAR PANELS I I I
(AIR QUALITY: 1000 FEET MATERIALS I I
NO NO NO I I FRA14E INSPECTION I
IFIRE SPRINKLER HANGERS
(INSULATION/WEATHER STRIP( I 1
1 1NTERIOR LATH/DRYWALL
(EXTERIOR LATH V
IRATED FLOOR/CEIL ASSEM. I I I
I I IRATED WALL ASSEMBLIES
I I I
IRATED SHAFTS/OPENINGS I I I
I I I
IT-BAR CEILINGS
I I I I
ILOT DRAINAGE
1REPORT ID: DPR261 ROUTE TO: BS0508