HomeMy Public PortalAbout5771-5801 ROSEMEAD BLVD_Building__ APDL M A014 FOR BUILDING PER IT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS -- - 1
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS
��
57"
5601
or a certificate of Workers'Compensation Insurance,or a certified CITY 7 — C6E / gLVD'
copy thereof Sec. 000,Lab.C.) C rJ�7 j — 5"i3Q QQS�lvi gLJP.
38, ��
Policy NO 4 Com -TeMPL C 1 I LOCALITY .�.�M PL-E G 1 Tv
7
SIZE OF LOT NO.OF BLDGS.NOW ON LOT
erti py sf here urnished. 1L.:T"71 S -7 V52- '�4t F.- NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TAT BLOCK LOT NO.
departm/en—tom' 2 to-a. t Q USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL /
(Q Z � ' G SPECIAL CONDITIONS
OWNERTEL NO.
CERTIFICATE OF EXEMPTION FROM WORKERS!- G �� Qi eL0P 21?),�
AN � WITHIN toxo Fr.OF SCHOOL? YES NO
COMPENSATION INSURANCE ADDRESS
µ
(This section need not be completed if the permit is for one hundred 2O oGr�6.-;E 120" FI-001z DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY
dollars($100)or less.) CITY ZIP t (�
I certify that in the performance of the work for which this permit LOM! r c/01302- J c•!/n 6 (J-Z � 3
Is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER EL 140.
become subject to the Workers'Compensation Laws. LAYMM Ae,:5 W- 4162 STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. Alf DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate of �S Va A4,1 WA115 REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you Should become Subject to the Workers' CON %R TEL NO. SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code,you must forthwith FRONT
comply with such provisions or this permit shall be deemed revoked. A LIFJ�Q�/o4
®/� �,p '��ff�d Q P L
LICENSED CONTRACTORS DECLARATION G/f (. LIC.C SIDE O
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP v
(commencing with Section 7000)of Division.3 of the Business and SO . NO.OF STORES NO. FAMILIES
Professions Code,an my license is in full force and effect. NEW BK PG o
Licence Number Lic:Class DESCRIPTION OF WORK ADD ❑ VAWATIOPI W
Contractor Da U.
` ! ALTER ❑ �~
❑ I am exempt under Sec. REPAIR ❑ 2 /8�� 373fl� -K5.,,I5
DEMOL ❑ 1 i BOE
8.8,P.C.for this reason ..•._
Date. TOTAL
USE OF EXISTING BLDG. URS ❑ LDMA P/C N
Signature ! APPLICANT(PRINT) T NO. LDMA Penn N
C,
❑
I.as owner of the property, or my employees with wages as - �ss' 8 ' 2. C Iv'HE1--it = y5°C-'
their sole compensation,will do the work and the structure is ADDRESS F• *' Ir
not Intended or offered for sale (Section 7044, Business and S VAS N U-15 Z-,1VP• % N N U-6• FINAL DATE > CHAA,N Gr
Professions Code.) VALLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIALVIL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN
1, asowner
er of the
topeft am Construct exclusively
xclluthe project (Secttong7with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BYIwI rljl}-1-i;l j i
Business and Professions Code. WILL
YES11 No 11L 1 1
OCC THE INTENDED USE MI THE BUILDING BY THE APPLICANT OR FUTURE ESOUNG -2) i Pr, 2:47.
OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH '
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST 3
FOR GUIDELINES. -Y dd�� -7
1 hereby affirm that there is a constriction lending agency for YES❑ NO❑
the performance of the work for which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD
3097,Civ.C.). PERMITTING CHECKLIST.1 UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES
COUNTYCODE,TITLE2,CHAPTER 220SECTIONS 220.100THR000H 220.140 CONCERNING
Lenders Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
Lenders AddressOWNMOR,GENr
o I certify that I have read this application and state that the above
infornatio rrect. I agree to comply with all county P.C.FEE ��/j' PERMIT FEE r�/^• D
ordinen n tete laws relating to building construction,end U 0( �
here representatives of this County to enter upon ISSUANCE FEE
the entioned pro r' pection pure ��
a INVESTIGATION FEE TOTA
maAppOm„I arAyo„t �.•-LLiLIJ'sz�G6�Y
L ( i4- SEE REVERSE FOR EXPLANATORY LANGUAGE 14f
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