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Home My Public Portal About5781 ROSEMEAD BLVD_Building__ 'WORKERS' COMPENSATION DECLARATION !,hsr affirm that I have certificate of consent self PLIC T I®N FOR BUILDING P E RM I T insure;,,of a rertlficate of Workers'Compensation Insurance,or a certifieckopy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING copy y ADDRESS AeV ❑ Certified copy is filed with the county building inspec- BUILDING " tion department. ADDRESS C LOCALITY Date Applicant CITY 41 NO. OF BLDGS.ZIP D706;,O REST 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. MAD BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL. OWNER NO. USE ZONE MAP 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 CONDITIONS a so as to become subject to the Workers'Compensation Laws. • OV /� CITY ZIP . ,• U ,Date r / Applicant �� v `-nf� ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE A PLICANT: If, after making this Certificate of ENGINEER NO. jj,rp CONST.1/ Z E [�T� O Exemption, you should become subject to the Workers' ADDRESS 'V v Y � C ✓ � a Compensation provisions of the Labor Code, you must forth- N with comply with such provisions or this permit shall be TEL•,8 STATISTICAL CLASSIFICATION APT. I CONDO. deemed revoked. CONTRACTOR OYlff- NO. LICENSED CONTRACTORS DECLARATION LIC. 6091 3 CLASS No. ELL. UNITS Z I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO' SEWER MAP (commencing with Section 7000)of Division 3 of the Business "LIC. and Professions Code,,and my license is in full force and affect. CIN 70a CLASS BK. PG. VALIDATION License Number 6v' 1� Lic. Classes SQ FT. STONO.RIES IE FA OF CHECK SIZE - STORIES FAMILIES ONE /� ? VALUATION Contractor "t�- �- `0AEL Date —v DESCRIPTION OF WORK NEW , ,( $ / /�1'77 orb ADD l�J C/a' ❑1 am exempt under Sec. ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL ❑ EXISTING BLDG. Signature APPLICANT T) t S NO.g FINAL e OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor's LicenseADDRESS rJPly- FINAL Law for the following reason (Section 7031.5, Business and .1 Professions Code): „ PRESENT By c d. 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. I,as owner of the property,am exclusively contracting CONTRACTOR NO. ;;t_::;::•�a with licensed contractors to construct the project (Sec- ADDRESS _ tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH ' y�-^[six•• I hereby affirm that there is a construction lending agency for FRONT t CE I•, the performance of the work for which this permit is issued D.L. P P r )ditH, -i G (Sec. 3097, Civ. C.). SIDE —x- P.L. NORM I !_i:I': +Tioti� Lender's Name ��! ��r% LDMA Ref. # 8 P.C. Fee$ a Permit Fee �J Lender's Address f"T �� ® � - I certify that I have read this application and state that the Issuance Fee T LDMA P/C# '- above information is correct. I agree to comply with all County Investigation Fee - ordinances and State laws relating to building construction, Total Fee • -� LDMA Perm. # cm he y authorize representatives of this County to enter '! _!�i t? y �.: s,a u on the bove- non property for inspection purposes. o , U Q6a�jtei& SEE REVERSE FOR EXPLANATORY LANGUAGE L Signature of Applicant or Agent WORKERS' COMPENSATION DECLARATION 96 "e /4e'-0�4 _ hereby affirm that I have certificate of consent to self APPLICATION FOR 3 U I L®I N G P E RM I T 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 ❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING PY Y ADDRESS ��- ❑ Certified copy is filed with the county building inspec- [AUDDRE DING /^� / �� tion department. SS l Thy Date Applicant L—� �L ZIP LOCALITY NO.OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' OF LOT NOW ON LOT COSSST.COMPENSATION INSURANCEASSESSOR(This section need not be completed if the permit is for one T BLOCK LOT NO. MAP BOOK PAGEPARCEL hundred dollars ($100)or less.) LL / TEL. ER 6 �L�C/� Np, USE ZONE MAP I certify that in the performance of the work for which this °S ��C � � SPECIALpermit is issued, I shall not employ any person in any manner RESS �� 'T/ CONDITIONS CL as to become subject to the Workers'Compensation Laws. O I f � CITY � �- ZIP V Date E L�Applicant �y` ARCHITECT OR TEL. 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' fI 2 CONS;/ NE U Compensation provisions of the Labor Code, you must forth- ADDRESS i.5 v 0 �r/ V rj ��.o a- with comply with such provisions or this permit shall be �A� �I' TEL-71 M STATISTICAL CLASSIFICATION APT. CONDO. to deemed revoked. CONTRACTOR f O� tl NO. -�L="!o , Z_ LICENSED CONTRACTORS DECLARATION �, r No s 3 CLASS NO. a DWELL. UNITS ADDRESS 71 I DLO r d`� ! I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP mmmiIiiiIiI (commencing with Section 7000)of Division 3 of the Business CITY ®,�� gLiL`� LIC. L'-44 and Professions Code and m license is in full force and elle N BK. PG. VALIDATION _ SQ. FT. NO. OF NO.OF CHECK License Number � � Lic. Class SIZE STORIES FAMILIES ONE J� Ie� / ; VALUATION Contractor- n�� to l r�7— � DESCRIPTION OF WORK �� ` NEW $ /L/�'C ❑I am exempt under Sec. _44±R tL7C �� t_ S- ADD 0 ( v ► ALTER ❑ B.BP.C. for this reason a� or,4� REPAIR ❑ $ Date: USE OF EXISTING BLDG. C-- '� t� DEMOL ❑ Signature APPLICANT ; f TEL•• FINAL OWNER-BUILDER DECLARATION (PRINT), 'O.y� /Y � e/� NOS• /�,�� a� DATE j'�'•-�� 17 1 hereby affirm that I am exempt from the Contractor's License ADDRESS�� . Y� u�� r' ��' � Law for the following reason (Section 7031.5, Business and FINAL Professions Code): PRESENT❑ By property,, or m employees ees with BUILDING I, as owner of the C P P Y Y P Y ADDRESS wages as their sole compensation,will•do.the work and ® �:'; ? ;_ ?C;' the structure is not intended or offered for sale(Section LOCALITY --- 7044, Business and Professions Code.) MOVING TEL. CONTRACTOR NO. I,as owner of the property,am exclusively contracting ~ - I with licensed contractors to construct the project (Sec-. ADDRESS tion 7044, Business and Professions Code.) rs- :- -• REQUIRED TOTAL SETBACK FROM EXIST. 1 J. -'' °L'*' 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. TOTAL - x (Sec. 3097, Civ. C.). SIDE AL ..i;..,°e2.� �3 P.L. L I_ .. - Lender's Name S � LDMA Ref. 9 !'i :',(�{� -!-� P.C. Fee$ Permit'Fee =!!� '- °-"- � Lender's Address _ I certify that I have read this application and state that the Issuance Fee eOV �� CDMA P/C 0 3 above information is correct. I agree to comply with all County Investigation Fee s 17011_1-4 111*1 ordinances and State laws relating to building construction, Total Fee (� CDMA Perm. q :,7r.� and her by authorize repress tatives of this County to enter cxi LL�_li n thaboke-m nt' ned-p perty for inspe !oppurp��oses. o (� ° / / SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Ap !cant or Agent Date 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 0612050060 PHONE: (626) 285-0488 ERT: LEGAL ID: NUMBER OF SIGNS: 1 BUILDING ADDRESS: ON FILE SIGN DESCRIPTION: NEW SET OF CHANNEL LETTERS 5781 ROSEMEAD BL _ TEMP CA 91780• ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LAS TUNAS 5397-012-043 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY, C TENANT: EXIST BLDG USE: ISSUED ON: PROCESSED BY: EXPIRES ON: H & R BLOCK EXIST OCC GRP: 12/05/06 JK 11/30/07 OWNER: TEL. NO: SLUGS. NOW ON LOT: VALUATION: FINAL D �II^ pL BY: CODE: 3709 INVESTMENT - 2,400 "RHR 3709 l SAN DIEGO, CA9211137 FEES PAID DESCRIPTION OF WOR NEW SET OF CHANNEL LETTERS FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: APPLICANT: TEL. NO: ROBERT SMITH (949) 689-8944- AA BLDG PERMIT ISSUANCE 27.75 26871 CALLS ALCALA AX BUILDING REVIEW FEE 54.70 SPECIAL CONDITIONS: MISSION VIEJO D2 PERMIT W/O EN-HC 2400.00 VAL 99.00 TOTAL FEES 181.45 CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE ROBERT SMITH (949) 689-8944- 26871 CALLS ALCALA LIC. NO LOCATION AND SETBACKS MISSION VIEJO, CA 92692 597275 C45 SOILS ENGINEER APPROVAL ARCHITECT OR ENGINEER: TEL. NO: FOUNDATION/TRENCH FORMS LIC. NO: SUPPORT STRUCTURE MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 00 N0. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: NO 20 SCHOOL WITHIN HAZARDOUS AIR QUALITY: 1000 FEET MATERIALS NO NO NO REPORT ID: DPR261 ROUTE TO: BS0508 n