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Home My Public Portal About5751-5757 ROSEMEAD BLVD_Building__ AP LIION FOR BUILDING PEF 0 T � COUNTY*OF'- SNGELES BUILDING AND SAFETI r FOR APPLICANT TO FILL IN BUILDING ADDRESS-- WORKERS COMPENSATION DECLARATION 1w 1 hereby affirm that I have a certificate of consent to self Insure, BUILDING ADDRESS ��_ — F3L�O p or a certificate of W5751 575 f2os�dal-�orkers'Compensation Insurance,or a certified CITY ZIP 575 I — 575 1 P-0515-:7-10010 �LJM> copy thereof (Sec 3800,Lab.C.) •��PL E -6-17-Y, LOCALITY Policy No. ��Compa T�J�1 PCC G Ty /� / SIZE OF LOT NO. BLDGS.NOW ON LOT NEAREST CROSS ST. 6'CertifI op is FidTe furnished. l� -7t 327. 132 5.-F' ❑ Certified copy is filed with the county buildinginspection TRACT BLOCK LOT NO. department. P 3&2 Q r 10 3 L. USE ZONE MAP NO. ` Date y/ Applicant � 7f ASSESSOR MAP BOOK PAGE D/n PARCESPECIAL CONDITIONS oil I 63 L 1.TELNO. CERTIFICATE OFEXEMPTION FROM WORKERS' CEFIOI� DE1!^�L-OP, ZI'i)�I3�' G� WITHIN 1000 FT.OF SCHOOL? YES NO COMPENSATION INSURANCE ADDRESS (This section need not be completed if the permit Is for one hundred 2ac QLc41J A'06-cr E 12T fl FLOOf�- DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) CITY ZIP 2 I certify that in the performance of the work for which this permit LQ/V4 8QN,1_H , 6A• 9a��Z 5. f3 g'2 J Lia Is Issued, I shall not employ any person In any manner so as to ARCHITECT OR ENGINEER TEL NO.�i become subject to the Workers'Compensation Laws. r IN • L I AIJ ASS O G• X818) / /-g ,j2 STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS _ 1 `` CLASS NO.�DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of I1ry(A�t'S P�LVD. V^" NuYS REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL.NO. SETBACK 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 LI . 0. P L VIAr!J" SIDE >' LICENSED CONTRACTORS DECLARATION cl LIC.c P o L C3 . 90� I hereby affirm that I am licensed under provisions of Chapter 9 �A SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT E NO.OF ORES NO.OF FAMILIESC Professions Code,and my license is in full force and eff t. NEW BK PG DESCRIPTION OF WORK . ADD ❑ VALUATION ® i W License Number L10.Class _ n. Contractor Date /��/ I _ L�I Al $ y ALTER ❑ � h4:�� n it � GG TY E .: ; ---. - ❑ I am exempt under Sec. REPAIR ❑ $ W-',.I�; _��1,, • DEMOL ❑ 4. I 1 T E#Ea B.flP.C.for this reason USE OF EXISTING BLDG. LDMA P/C# Date: d.7— 91 URM ❑ TOTAL 2i'S3J;a 4r Signature APPLICANT(PRINT) TEL NO. LDMA Penn# !��j[ ("�V{ -t---• - Z L.•1-1E4r[t sig-'•irLl a�'i'? ❑ I, as owner of the property, or my employees with wages as C their sole compensation,will do the work and the structure is ADDRESS F- ;;LfhN17t ilk not intended or offered for sale (Section 7044, Business and K5 1:5 U i�,�L� V r/ FINAL.DATE G , Professions Code.) WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL ,`Z— 2 0^ l TER THAN i I, 88 owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREA THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY \ a ` 1 00010 LILIiI •�?.J% y 4 licensed contractors to construct the project (Section 7044, YES❑ NO❑ r r Business and Professions Code.) '' 1 tr;; r WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING �� 16. I .: i='?.i OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH • CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST v FOR GUIDELINES. I hereby affirm that there is a construction lending agency for FYES OR No❑ the performance Of the Work for which this permit is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD 3097,Civ.C.). PERMITTING CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,TITLEZ CHAPTER 220 SECTIONS 2.2D.100THROUGH 220.140 CONCERNING �J v Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. / Lender's Address OMEAORAGMT A /i�/ 0 1 certify that I have read this application and State that the above P.C.FEE .Q/ PERMIT FEE Information is correct. I agree to comply with all county ordinan and State laws relating to buildingconstruction,and hereb uthoriize representatives of this County to enter upon ISSUANCE FEE 6� th mention for Inspection purposes. • .1 !' (� / INVESTIGATION FEE TOTAL F (/ ® e mWro'NApgku4or Q SEE REVERSE FOR EXPLANATORY LANGUAGE i� �o ' 04 WORI -OMPENSATION DECLARATION hereby affirn I have a certificate of consent to self % P L I fm r I N F 3 U ®I RM insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.)• COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS e Date 17A/Applicant CIN 6/1V ZIP LOCALITY NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 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.) �O oOWNER NO. USE ZONE MP I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL d CONDITIONS so as to become subject to the Workers'Compensation Laws. 0 CITY s/� ° ZIP Date Applicant ARCHITECT TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0 NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NO. o CONST. ZONE V Exemption, you should become subject to the Workers' �' W Compensation provisions of the Labor Code, you must forth- ;..ADDRESS eJ a with comply with such provisions or this permit shall be TEL 1/�� STATISTICAL CLASSIFICATI A GOND Z deemed revoked. r'CONTRACTOR ��/��/� NO. •6 LICENSED CONTRACTORS DECLARATION -1102- (commencing CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS SEWER MAP with Section 7000 of Division 3 of the Business LIC. •L�•- nd Professins Code,and my license is in full force an effect. CITY G✓r7 L' CLASS L' BK. PG. H' VALIDATION -� o SQ. FT. O.OF NO.OF CHECK �yF f iL+i:■:L: License Number 5 A 1 l t' Lic. Class SIZE STORIES FAMILIES ONE s. _�� GY'1711 / 17. / DESCRIPTI ORK NEW ❑ "i. VALUATION ; T�— MIS Contractor ate � $ J�� I�(i [..�• f� ADD ❑ ~� I O k AL. 156 - 83 ❑I am exempt under Sec. ALTER r �.�t-ri ❑ �:d-ECK 1•t:°■L BAP.C. for this reason IREPAIR ❑ ^?. $ 8/ tti-O Date: USE OF • �i+.�6#t �1 I. EXISTING BLDG. DEMOL ❑ APPLICANT TEL °:t~Li( 3°■s}- Signature (PRINT) NO /,� FINAL . OWNER-BUILDER DECLARATION DATE �ZB-� f�rls! !-LiLI;l s fF�.-, I 1 i I hereby affirm that I am exempt from the Contractor's License �,� ..JJ'�� . Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Z, l"i`l11,1�• Professions Code): PRESENT Ilsy I�rr ■r _- ❑ I, as owner of the property, or m employees with BUILDING °' 7 Zlj, :;=_I,�� P P Y� Y `'ADDRESS � o[ •] wages as their sole compensation,will do the work and LocAurr 1;Et': the structure is not intended or offered for sale(Section /C. 7044, Business and Professions Code. MOVING TEL. � �--■ -_:":3 CONTRACTOR NO. -•2 - �� i E ITAL `�' �'4 `� ❑ I, as owner of the property,am exclusively contracting yg' •o-p __ with licensed contractors to construct the project (Sec- ADDRESS HED'""� 374u=_ tion 7044, Business and Professions Code.) `f71 ._ r REQUIRED YARD HWY TOTAL SETBACK FROM EXIST, s:His 4GE ■Imo( CONSTRUCTION LENDING AGENCY SET BACK 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. (Sec. 3097, Civ. C.). SIDE 0r I t_.Ir_10 J iL _ i. ./`r". P.L. Lender's Name // p / LDMA Ref. q r f v4tif il��,■ I S P.C. Fee$ �Z*d 3 �S �- Permit Fee Lender's Address � •: I certify that I have read this application and state that the /' �O Issuance Fee / ` fit? LDMA P/C# pool '- above information is correct.I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee ;Z LDMA Perm. N x and hereby auth a rept Vn is County to enter upon thea nsp County ones. f✓ SEE REVERSE FOR EXPLANATORY LANGUAGE !gnat pl can r Agent Date WORKERS' COMPENSATION DECLARATION hereby affirm that I have certificate of consent to self APPLICATION F O BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, �'+ or a certified copy thereof(Sec. 3800, Lob. C.) COUNTY OFlb-9 ANGELES BUILDING AND SAFETY Policy No. Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS d7 �.S/ /G�Q� ❑ Certified copy is filed with thh u ty building ins ec- BUILDING -�55 (j am tion department. ADDRESS f Date -7h 1 Applicant CITY ZIP LOCALITY ID NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 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 BOOKPAGE PARCEL hundred dollars ($100)or less.) USE ZONE MAP OWNE O• NO. 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 t� CONDITIONS a•• so as to become subject to the Workers'Compensation Laws. O CITY ZIP Date Applicant ARCHITECT OR TEL. DISTRICT GROUPty NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO CONST. ZRNE PROCESSED BY Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be /1 TEL• SJR T TICAL CLA F CATION T C A. Z deemed revoked. CONTRACTOR j J NO. i _ LICENSED CONTRACTORS DECLARATION `n LIC. q ! NO. DWELL. UNI I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 3 Ur71 �'C7 �-i S7 NO. I G��l r (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP CITY i Ori �W °11766 cL- r--Iv C-6f`` and Professions Code,and my license is in full force and effect. / BK. PG. VALIDATION License Number .�C-16 v t I Lic. Class��d C-� ' EFT STORIES FAMILLIIES ONE VALUATIO K p J DESCRIPTION OF WORK ,cep NEW $ U �� 17 Contractor l� Date ADD ❑ . r iL ❑I am exempt under Sec. ALTER ❑ "`� TOT }I �...-; •_,•.� $ (O�t1L �' a'j .. +F8 BAP.C. for this rens n REPAIR ❑ �' _ _ _ ote' EXISTUSE OING BLDG. DEMOL ❑ ` f`j I:'_'ti , i a°JL Signature (ted l-P11452� APPLICANT TEL. " FINALHAN1'3l•: (PRINT) NO. OWNER-BUILDER DECLARATION , DATE q, I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS y FINAL ^,l;! k i i ;i•7J;,-� Professions Code): PRESENT By - ' = BUILDING k, - .-, ❑ I, as owner of theproperty, or m employees with '�1 i)1;1 ' YADDRESS 3 + - wages as their sole compensation,will do the work and LOCALITY Dip. 3� the structure is not intended or offered for sale(Section /r 7044, Business and Professions Code.) MOVING TEL. ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- �7• ADDRESS tion 7044, Business and Professions Code.) REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK 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. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name l& / LDMA Ref. # 8 P.C. Fee$ Permit Fee 'l / 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 7 �` 3 ordinances and State laws relating to building construction, Total Fee / +� LDMA Perm. # and hereby authorize representatives of this County to enter g upon the above-mentioned property for inspection purposes. o SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date