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Home My Public Portal About5803-5807 ROSEMEAD BLVD_Building__ PPLI , , D FOR BUILDING R T COUNTY 016S S ANGELES +� BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN DI G ADDR 1 hereby affirm that I have a certificate'of consent to self insure, But A/p/p��ES�sb or a certificate of Workers'Compensation Insurance,or a certified V J copy thereof Sec. Lab.C.) try ZIP . LOCALITY Policy No. �v Compar� �� EfyridLG' '�/ ,,�� 91 E T O NEAREST CROSS ST. Certified s hereby�umish ed. ❑ Certified copy Is filed with the county building inspection TRACT . BLOCK T N��Jj departmen). K ®Ls 1®�� USE ZONE MAP NO.A709aW Me r Date�// Applicant��-• s A —SPECIAL CONDITIONS J CERTIFICATE OF EXEMPTION FROM WORKERS' NO. COMPENSATION INSURANCE RESS WITHIN 1000 FT OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundredDISTRICT TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) C ZIP I certify that in the performance of the work for which this permit f}� Is issued, I shall not employ any person in any manner so as toR ENGINEER become subject to the Workers'Compensation Laws. 1 _ STATISTICAL C/LA,4�$IFICATIONAPT CONDO DR ® Date Applicant r+ CLASS NO._L(L—DWELL UNITS NOTICE TO APPLICANT.• If, after making this Certificate of Y REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' C OR TEL.NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed-revoked. q LIC.NO FRONT �C PL fV --, >- LICENSED CONTRACTORS DECLARATION I �1 y LI PILE -k CD 1 hereby affirm that I am licensed under provisions of Chapter 9 �? /� SEWER MAP Hu,l a= v. (commencing with Section 7000)of Division 3 of the Business and 0.OF ORES NO.OF FAMILIES _ Professions Code,an my license is in full force and a act. •`_1 ' NEW BK PG 1,4�s f E t o-r, License Number �fo1Y16 c.Class D RI o wo J-0, ADD ❑ VALUATION Contractor / A0_41-T/ ALTER ❑ ITEMS' y TOTAL �??74 ❑ I am exempt under Sec. REPAIR El $ CHECK 1777.5" BARC.for this reason DEMOL ❑ � �t Date' a ��s� USE OF EXISTING BLDG. uRM ❑ LDMA P/C# is CHANGE .00 Signature P (PAI T) LOMA Perm# ❑ I,as owner of the property, or my employees with wages as Z, 0000-0001 u%Lei RD their sole compensation,will do the work and the structure is ' L'r4J i (�j 11�; not Intended or offered for sale (Section 7044, Business and �It� FINALgp+ Professions Code.) asL _L} WILLTHEAPPLICANTOR FUTURE BUILDING OCCUPANT DLEAHAZARDOUS MATERIAL i J 1, as owner of theproperty, am exclusive) contracting With ORA MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Y 9 THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project.(Section 7044, YES❑ No❑ , Business and Professions Code.) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. 277 1 hereby affirm that there is a construction lending agency for YES❑ No❑ r" -, _i F..I the performance Of the work for which this permit is issued(Sec I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE r31 '_�; , 3097,CIV.C.). PERMITTING CHECKLIST.t UNDERSTAND MY REQUIREMENTS UNDER THE LOS AN m , ? TJ• ^"••( 4 • OpUNTYCODE,TITLE 2,CHAPTER 220 SECTIONS 220.100THROUGH 220.140 CONC ^( CaY -•,�^ I-•- f„� �� 777"(0 Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE r.i Fi a Lender's Address OWNmoRAGW e� ' o• 1 certify that I have read this application and state that the above __ M� information rrect. I to comply with all county P.C,FEE PERMIT FEE�� Q ordin nd State I ti g to b 'Iding construction,and of CJ here authorize rep I of Soo to e r upo ISSUANCE FEE I j t"J F :e th mentioned a for Pact!o urp �� — '.R `-'t I INVESTIGATION FEE TOTAL F �O/ I•.:I o w' I—� 1^` Sig MW • �w -77-&.-� L Q a,..�_ ..� /� s siii E 1�; Bldllllwf)Alf`�ANGUAGE, WORKERS' COMPENSATION DECLARATION hereby affirm that I have insure, or a certificate of Workers' certificate of consent-to self kers' Compensation Insurance, APPLICATION FO R BUILDING P E RM I T or a certified copy thereof(Sec. 3800, Lab. C.) COUNT( OF LOt ANGELES BUILDING AND SAFETY Policy No. Company BUILDING El ��'�� 7 lJ Certified copy is•hereby furnished. FOR APPLICANT TO FILL I'N ADDRESS / 10u�.fi� d' ❑ Certified copy is filed with th o ty buildin ' ec- BUILDING t -1 tion depart Ott.. ADDRESS 59n3- J� 1 DateApplicant ` CITY T ` ZIP LpCp,Llnj CERTIFICATE OF EXEMPTION FROM WORKERS' NO. F BL NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOOT T CROSS ST. ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK 'LOT NO. ' MAP BOOK I PAGE PARCEL hundred'dollars ($100)or.less.) IrEL OWNER O• USE ZONE MAP I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in any manner ADDRESS C SPECIAL CONDITIONS CL so as to.become.subject to the Workers'Compensation Laws. OO CITY ZIP Date Applicant ARCHITECT OR TEL. 0 NOTICE TO APPLICANT: If, after,making this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE P OCESSED BY gD /y n� CONST ZONE LU Exemption, you should" become subject to the Workers' OY bp/}- v V Compensdtion provisions of the Labor Code, you-must forth- ADDRESS a with comply.with,such provisions or this permit shall be } �} ti TEL. �T S71CAL SSIFICATIO CONDO. Z deemed revoked. CONTRACTOR NO. _ LICENSED CONTRACTORS DECLARATION LIC �j SS NO. DWELL. UNI .I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS C F00 R ANO. LJ-I o� n LIC. �•• SEWER MAP (commencing with Section y license of Division 3 of the Business CITY POtIOAIA c h -7n6G CLASS—"�O C�G� and Professions Code,and my(�license is in full force and effect. ( gK pG. VALIDATION License Number 6-5��" Lic. Class• C•��O I SIE STORIItS FAMILLIIES ONE K VALUATI t� Contractor 821' Date 11 1 DESCRIPTION OF WORK T(itP t NEW y '[ ❑I am exempt under Sec. ADD E-11 'w5 hs770 ALTER ❑ r o BAP.C. for this reason REPAIR ❑ $ E 7_ DatIE II, e USE OF * EXISTING BLDG. DENIOL El L 7 1L33 Signature ' APPLICANT TEL. , (PRINT) 'NO. FINAL y i• Gr•I': n- 1:.: OWNE -BUILDER DECLARATION. DATE I hereby affirm that I am exempt from the Contractor's License CHANGE jj� Law for the following reason (Section 7031.5, Business and ADDRESS FINAL -1- Professions Code): PRESENT By BUILDING El 1, as owner of the property, or my employees with ADDRESSa �3 + Ct e9 i r 0 wages as their sole compensation,will do the work and `I`t `-L'zf= z I/2 ! _ the structure is not intended or offered for.sale LOCALITY ale(Section Q,��. �{ 7044, Business and Professions'Code.), - MOVING TEL. /• 07 � ri111 113 7 ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) . REQUIRED TOTAL SETBACK FROM EXIST. �y CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH ��d I hereby affirm that there is a construction lending agency for FFRONT -the performance of the work for which this permit is issued L. (Sec. 3097, Civ. C.). DE L. Lender's Name. p LDMA Ref. # Lender's Address Fee$ 2O Permit Fee r��{• I certify that I have read this application and state that the Issuance Fee a` / Zr 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 r /� O O LD Mq perm. # and hereby authorize representatives of this County to enter upon the above-mentioned,property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date WORN :OMPENSATION DECLARATION hereby affirrr ® I have a certificate of consent to self P `I Crx ®1N F o R a llI L D I N GPERM I insure, or a certificate of Workers' Compensation Insurance, ®-`r or a certified copy thereof(Sec. 3800, Lab. C.), COUNTY OF LOS ANGELES BUILDING AND SAFETY. Policy No. 2!f Company L' �Z' �� 1�'Ul O Certified copy is hereBUILDING by furnished. FOR APPLICANT TO FILL IN -/ ADDRESS c� 4G e 7 Certified copy is filed with the county building ins ec- BUILDING cr o 3— Sls� Pfsy CSF /// tion department. ADDRESS 1 , r � Date lk plicaht CITY ' �� ZIP LOCALITY f NO.OF BLDGS. NEAREST CERTIFICATE bF EXEMPTION.FROM WORKERS' SIZE OF LOT/F 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.) . :LINO. OWNER 01 j IDA/ LNO. USE ZONE MAP I certify that in the performance of the work for which this if NO. SPECL permit is issued, I shall not employ any person in any,manner ADDRESS C CONDITIONS CL soas to become subject to the Workers'Compensation Laws. O CITY ZIP U DateApplicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY M NOTIG TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE 0 Exemption, you should become subject to the Workers' u Compensation provisions of the Labor,Code, you must forth- ADDRESS with comply with such provisions or this permit shall be • IC TEL. r I_^/� STATISTICAL CLASSIFICA ON. CONDO. N deemed revoked. CONTRACTOR 1 A NO: �j "� -Z LICENSED CONTRACTORS DECLARATION LIC. u CLASS NO. DWELL. UNI 2. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Of �. 6;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. CITY oI"lo CLASS e BK. 'VALIDATION g SQ. NO. OF NO. OF CHECK License Number '� v Lic. Class C, 1� SIZE STORIES FAMILIES ONE �•� VALUATION Contractor -Date r, DESCRIPTION OF WORK NEW ❑ f fir= 33607 1 5.:5 KL; o ElI am exempt under Sec. d' •r., b►u ADD ❑ Poo. t,: 1 TT EMIR: B.BP.C, for this reason ALTER ❑ �� _ " -1156 2.3 USE REPAIR ❑ Date: EXISTING BLDG. C� .0 ��` ., DEMOL ❑ �L-t� �� JIM APPLICANT TEL, pk Signature (PRINT). - NO. OC"%--'� FIFIAL I OWNER-BUILDER DECLARATION DATE �[�- I hereby affirm that I am exempt from the Contractor's License ADDRESS �'Q Z �/�'+� 4f' ' a Law for the following reason (Section 7031.5, Business and FINAL. ti•%t o 0 Professions Code):. PRESENT. ri, By. 1-> -111�I} At BUILDING .❑ I; as owner of the property, or my employees with ADDRESS .?' j y? _ " wages as their sole compensation,will do the work and ." "�` i a 1 1. the structure is not intended or offered for sale(Section LOCALITY ®T PC. 7044, Business and Professions Code. MOVING TEL. - �'-` CONTRACTOR NO. I,as owner-of the property,am exclusively contractingn, _with licensed contractors to construct the project (Sec- uL:(� 3.3- 10 :• -' ADDRESS __ tion 7044,Business and Professions Code.) +t jl ' REQUIRED TOTAL SETBACK FROM EXIST. CHANGE 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. - e (Sec. 3097, Civ. C.). SIDE 01,0110-0001 - CS/ /?b ' Lender's Name P.L. 7 733 1 Aid 10'43 / (�Q , 1 P.C. Fee$ �(G• 0 J permit Fee /e' 1-44C LDMA Ref. # Lender's Address / I certify that I have read this application and state that the O0 Issuance Fee ��' b LDMA P/C# above information is correct. I agree to.comply with all County Investigation Fee. �.(( O ordinances and State laws relating to building construction, Total Fee da �' LDMA perm. # and hereby authorize represents' es tis County to enter upon the VrWJ, spection pu poses. 7 SEE REVERSE FOR EXPLANATORY LANGUAGE Signal e f ppllcant or Agerit Date