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HomeMy Public PortalAbout5805 ROSEMEAD BLVD_Building__ WORKERS' COMPENSATION DECLARATION hereby affirm that I have urcertificate of consent to self APPLICATION F ORBUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY P li y No. 12-b93 Company- BUILDING 7 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS .l�dJr /� ,s✓drt_e /❑ \Certified copy s filed with the county, uilding inspec- BUILDING /� Tion depar S. ADDRESS `v..ss,,• 0,S9l� J_, Date Applicant CITY M C `r ZIP LOCALITY NO.OF BLDGS. NEAREST CERTIFI T OF EXEMPTION FR J1I1 RKERS' SIZE OF LOT NOW ON LOT CROSS ST. MPENSATION INSURANC ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) OWNER zll ��j�(_' �/� �eST N0. �9- USE ZONE MAP I certify that in the performance of the work for which thisNO. SPECIAL >- permit is issued, I shall not employ any person in any manner ADDRESs::Fya-:�- CONDITIONS it so as to become subject to the Workers'Compensation Laws. ` /7�v OU CITY rte-- ZIP Date Applicant ARCHITECT OR TEL. FIRE Q NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP TYP PROCESSED BY FIRE �- Exemption, you should become subject to the Workers' �Or jNE U Compensation provisions of the Labor Code, you must forth- ADDRESS a with comply with such provisions or this permit shall be ix-.t p,-�frr EL. STATISTICAL CLASSIFICATION 'APT. CONDO. N i�W F*+t&-.t ..,�rr Z deemed revoked. CONTRACTOR NOtt3-7� LICENSED CONTRACTORS DECLARATION LIC. /•Ips CLASS NO. 47142% UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS W (,✓A$r(/ DAJ�l.NO.�7/o O a (commencing with Section 7000)of Division 3 of the Business n LIC. r SEWER MAP and Professions Code,and my license is in full force and eff ct. CITY f+`� ec� /Odd CLASS C'��b BK. PG. VALIDATION SQ. FT. NO. OF NO.OF CHECK License Number S Lic. Class C` SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW $ /0.00 03L ❑1 am exempt under Sec. nm, suppa ADD ❑ 11110.(� ALTER El B.BP.C. for this reason k � r LmREPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL 2 Professions Code): PRESENT BY ACCToQ El1, as owner of theproperty, or m employees with BUILDING YADDRESS 3303 50.50 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 1 7044, Business and Professions Code.) MOVING TEL. ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. ACCT.11r o� with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) 330,E 92.}5 REQUIRED TOTAL SETBACK FROM EXIST. TrE'I CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH tt 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� els (Sec. 3097, Civ. C.). SIDE. P.L. CHECK 142.75 Lender's Name S L`� �-d - �J LDMA Ref. p CHANGE o00 P.C. Fee$ 0• Permit Fee �J � Lender's Address , I certify that I have read this application and state that the Issuance Fee .�d LDMA P/C# above information is correct. I agree to comply with all County Investigation FeeZ 0000-0001 6/10/96 ordinances and State law relating to building construction, Total Fee ��� LDMA Perm. ## 770 and hereby aut orize Agentafive�is County to enter 70 1 AM 9sp08 upon the abo -mentipertspections purposes S —ef N� _ SEE REVERSE FOR EXPLANATORY LANGUAGE SignadAe of Applicant r Agent Date APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BU"' ADORES UILD G ADDRESS O' 03 ��• ' •I hereby affirm that I have a certificate of consent to self insure, C`.� t h ��,^t�('C or a certificate of Workers'Compensation Insurance,or a certified copy thereof(,�e� T La .) h G �, ' 1 zip 1 1 Q (,.r 'rl• LOCALITY%// Policy No. ~ Company SI E OF L NO OF BLDGS.NOW ON LOT /- ❑ Certified copy is hereby furnished. NEAREST CROS ST SoIr- 1:1 Certified copy is filed with the copmy building inspection TRACT BLOCK LOT NO. de artmen1j.. / ( USE ZONE MAP NO. Date ^-10 ` Applicant ( 6 ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' YES jy� /f G�. -TEL NO T, " COMPENSATION INSURANCE /rTT L� /V U - -6 WITHIN 1000 FT.OF SCHOOL? NO ��++ (This section need not be completed if the permit is for one hundred ADDRES dollars($100)or less.) -f5-,f.:7-J- ��,/� DISTRICT GROUP S3 NE PROCESSED(3Y I certify that in the performance of the work for which this permit CIT ZIP , i7�v X is issued, I shall not employ any person in any manner so as to , become subject to the Workers'Compensation Laws. ARCHITE OR ENGINEER TEL NO. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' NTRA R -�. LNO �,r.n 1, SETBACK YARD HWY PRO i E WIDTH Compensation provisions of the Labor Code, you must forthwith ( 7P,0- l =� FRONT comply with such provisions or this permit shall be deemed revoked. DDRES 'nf IC.NO. P L AC(1T o v > (L•C ir o ) (s C) SIDE -,-, -, n LICENSED CONTRACTORS DECLARATION '` f,77 LIC:CLAS$ PL s�.S ,9 0.1kc 1 hereby affirm that I am licensed underprovisions of Chapter 9 (. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and O. .SIZE NO.OF STORIES NO.OF FAMILIES 1 ITEMS fY Professions Code and li n e is in full force and eff t. NEW ❑ BK PG , 30 o 7 r,C y TOTAL '� License Num er `7 Lic.Class '"I SCRIP,TION of WO ADD VALUATION Contractor 1`Vf tf( Date 'Z 41 `� 1 Zon C• ��`� ALTER $ ���' s � E� ��'�o�� ❑ 1 am exempt under Sec. REPAIR ❑ B.BP.C.for this reason DEMOL ❑ LDMA P/C# 0000_0001 1/28/96 Date: USE OF EXISTING BLDG. ❑ Signature APPLICANT(PRINT) TEL NO. URM LDMA Perm# 16594 1 Ate E.,18_ 1:1I, as owner of the property, or my employees with wages as Z A�C I o a their sole compensation, will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and FINAL DATE a3303q ITEMS q EI S y�+ 70°80 Professions Code.) coo- WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL L`� 1 I 1 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE El1, as owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY ' licensed contractors to construct the project (Section 7044, YESTOTAL 70 _ 4.P0 W Business and Professions Code.) WILL 1:1 No 11 _ WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK 70.80 OCCUPANT REQUIRE A PERMIT UTH or COAST AIR QUALITY MANAGEMENTRDIISSTR GT SCAOMDSTRUCTION R EE PERMItt NG C ECKLISN FROM THE TOFOR CONSTRUCTION LENDING AGENCY GUIDELINES CHANGE °G�I I hereby affirm that there is a construction 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 PERMITTING �} ^ {��y 4 �7 f 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. 0000--0001 5/2896 ' SECTIONSTITLE 2.CHAPTER 2 FOR 2 20.100 THROUGH 2 20.140 CONCERNING HAZARDOUS 9Lenders Name MATERIALS REPORTING D OBTAINNG A PERMIT FROM THE SCAOMD. o 6600 1 AM 10 12 Lender's Address OWNER OR AGENT I certify that I have read this application and state under penalty c of perjury that the above information is correct.I agree to comply P.C.FEEryD �p PERMIT FEE rn with all county ordinances and State laws relating to building d ' ' M . construction, and hereby authorize-representatives of this County ISSUANCE FEE O to r upon the above-menti6ned property for ins ection rpose . funINVESTIGATION FEE TOTAL FEE xo� a APP--I m A001mu G• !/ SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESSl- I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS y� or a certificate of Workers'Compensation Insurance,or a certified CITY ZIP b• ��� �-� L'I T� ` G �I/� f �� copy thereof(Sec.3800,Lab.C.) f✓ CA q I g p LOCALITY Policy No. Company SIZE OF LOT NO OF BUGS.NOW ON LOT 11 Certified copy is hereby furnished. NEAREST CROSS ST LOCK LOT NO. 13 Certified copy is filed with the county!wilding inspection TRACT B department. USE ZONE MAP NO. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO COMPENSATION INSURANCE pW , C ,PTHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS DISTRICT GROUP ;LONST FIRE ZONE PROCESSED(3Y dollars($100)or less.) I certify that CITY ZIP the performance of the work for which this permit ^� LsU� is issued, I shall not employ any person in any manner so as to G, become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO. Date Applicant ��+1 I W �.. ADDRESS CLA�TISS COAL CLASSIF1CATIDWELL UNITS APT CONDO NOT)CE TO APPOCANT.• If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROPLINE WIDTH Compensation provisions of the Labor Code, you must forthwith W +44-6(*?i FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS L1C.NO. PL y bYz66r SIDE a LICENSED CONTRACTORS DECLARATIONC CITY!—:,o ..�� �O LIC.CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORIES •NO.OF FAMILIES SEWER MAP Professions Code, nd my license is in full force and effect. NEW ❑ BK PG H Cr�_ DESCRIPTION OF WORK VALUATION ® L License Number �- -� LI,.Class ADD ❑ LL Contractor 1�%��W Date 7""f a=q 6 ALTER ❑ 441 �O EL ❑ 1 am exempt under Sec. REPAIR ❑ $ Z B.BP.C.for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ 23 Signature APPLICANT(PRINT) TEL NO. LDMA Perm# a ❑ I, as owner of the property, or my employees with wages as Z ACCT s= their sole compensation, will do the work and the structure is ADDRESS O 3303 50.50 riot intended or offered for sale (Section 7044, Business and FINAL DATE C Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THEJ /y}� ❑ 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY` .5. ACCT e v licensed contractors to construct the project (Section 7044, ,YES❑ NO❑ Business and Professions Code.) 3303 110.70 WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH '� ITEMS CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR .. L GUIDELINES. I hereby affirm that there is a construction lending agency for GYESUIDELINES No❑ TOTAL 16� _20 the performance of the work for which this permit is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING CHECK 161°20 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, InTITLE 2.CHAPTER 2.20 SECTIONS 2 20.100Lender's Name MATERIALS REPORTING AND FOR OBTAIN NGTHROUGH A PERMIT FROM THE2 20.140OSC OMD ERNING HAZARDOUS CHANGE 613 Lender's Address ` til i J QNNER OR AGENT cc 3 I certify that I have read this application and state under penalty t 1`� nft l i n a P.C.FEE PERMIT FEE 0000-01001 7f 1.V96 c of perjury that the above information is correct.I agree to comply �D end with all county ordinances and State laws relating to building � - 7 7t�u 1 (� if m construction,and hereby authorize representatives of this County ISSUANCE FEE .�j , Ai-- to �✓ to enter upon a above-mentioned property for inspection pur o s. of eJ ��� pp INVESTIGATION FEE TOTAL FEE 7 \! SEE REVERSE FOR EXPLANATORY LANGUAGE %. APPLICAMON FOR BUILDING PERMIT • COUNTY OF LOS ANGELES r BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS p 1 J, I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS e5 G�� or a certificate of Workers'Compensation Insura e,or a cert%fed d V. B +r COPY thereof(Sec.3800,Lab.C.) CITY E./• ZIP W LOCALITY P licy,.090M, ��' Compo Z c, lG L �yoG _/__9 SIZE OF LOT NO OF BLDGS.NOW ON LOT �+ rtified copy Is ere y furnished. NEAREST CROSS ST ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. depar ent. A/� USE ZONE MAP NO. Date Applicant /' lac >^^� ASSESSOR M BOOK PAGE PARCEL 97 AR SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNERll EL NO. YES NO WITHIN 1000 FT OF SCHOOL? COMPENSATION INSURANCE G1L/�G /� d© ��� D (This section need not be completed if the permit is for one hundred ADDRESS A9f Ld� �i41. ,o DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED 8Y dollars($100)or less.) ?S I certify that in the performance of the work for which this permit CITY v G�y ZIPC&I/ is issued, I shall not employ any person in any manner so as to L ! ARCHITECT OR ENGINEER TEL N NO. become subject to the Workers Compensation Laws. � Z ,,� STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS "� ' ' CLASS NO. �oZ DWELL UNITS NOTICE 70 APPLICANT If, after making this Certificate Of 5 l L �' AOr6 6, S -d// REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith z - C << G U �—f s' FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL } 4 _ CL LICENSED CONTRACTORS DECLARATION CITY �' LIC.C S PIDLE C I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ. I E NO.OF STORIES NO.OF FAMILIES M Professions Code,and my license is in full force and effect. • fdj NEW ❑ BK PG �`t--r O License Number 423,7,-1 Lic.Class �� DESCRIPTION OF WORK ADD ❑ VALUATION , AC-t-I e a (� Contractor &2-- �t,Date • O 33OS 515.53) ALTER d ❑ 1 am exempt under Sec. ° REPAIR ❑ $ 1 ITEMS z n 525 -53 BBP.C.for this reason NeZff / / �dam,�fc[�f/�?f DEMOL ❑ LDMA P/C o I'uL'IIf*T-AU(�- Date: USE OF EXISTING BLDG. URM ❑ �.r7ECK 515.°6 Signature t GC .00 APPLICANT(PRINT) l L O. ` LDMA Perm a �,Hj-1��� ❑ I, as owner of the property, or my employees with wages as �� L•/ / 3 2 Z -+ L16.89 their sole compensation, will do the work and the structure is ADDRESS O 3303 not intended or offered for sale (Section 7044, Business and .OA/ s !/y~/ FINAL DATEF C —� •O Professions Code.) C o� IOW11 4/ Li r WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL Ti �r ,r•t1E.,t..�yp:r i3r7 ❑ 1, 83 owner of theproperty, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE - 6 F.11- CM52/ y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project (Section 7044, YES❑ No❑ CHECK 616.89 Business and Professions Code.) WILL THE INTENDED USE THE BUIBY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION aUCTION OR MODIFICATION FROM THE SOUTH t-C!f'iL� 00 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES 11NO❑ -SS the performance Of the Work for which this permit is issued(Sec. IHAVE READ THE HAZARDOUS MATERIALS INFORMATIONGUIDE AND THE SCAOMDPERMITTING 00LIO-0011 41.25/96 3097,CIV•C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, f'1 a, e Lender's Name TITLE MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROMCHAPTER 2 20 SECTIONS 2 20.100 THROUGH 2 20 Q0 CONTHE SSCCAEORNINIDNG HAZARDOUS !jl rr��1 1 1 111 °t'-^ Lender's Address OWNER OR AGENT 3 1 certify that I have read this application and state under penalty p of perjury that the above information is correct.I agree to comply P.C.FEE r PERMIT FEE with all county ordinances and State laws relating to building mconstruction,_and hereby authorize representatives of this County ISSUANCE FEE �• O $ en r efprenti property for inspection purposes. b ,/ INVESTIGATION FEE TOTAL FEE J/�J ; N �'(\ Uro Of AMWcmM w MOMN i f' w__ / I fJ / I SEE REVERSE FOR EXPLANATORY LANGUAGE