HomeMy Public PortalAbout5821-5827 ROSEMEAD BLVD_Building__ P I ION FOR BUILDING PERAT �1
A NTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS O4���?C
I hereby affirm that I have a certificate of consent to self Insure, BUI G A /
or a certificate of Workers'Compensation Insurance,or a certified ZIP i
Copy thereof(Sec.3800 Leb.C.)_ • � �o� � LOCALITY � --
Policy NNo. J ,��p ewo Comp S O A!/�Qf� O.OF BLU".N O T
ErCrlfCOpy ie he fumished. /� �� f, � JWA NEAREST CROSS ST.
❑ Certified copy Is filed with the county building inspection BLOCK LOTK9A �® USEZONE MAPNo�,O
department.E /Je-Z A(G�
Data Applicant.., -e AS3 O PAG SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' O1N ER,gm p� Q/ ,j��. TEL NO. _ YES No
COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL?
ADDRESS ..�J
/�1 DISTRICT � TYPE CONST.' FIRE ZONE PROCESSED BY
(This section need not be completed if the permit is for one hundred fjd /�j� C��}%� /s� f/oo,�
dollars($100)or less.) yTY� ZIP /}
I certify that in the performance of the work for which this permit �C A/6 yi �0�D� (/O ✓'
Is issued, I shall not employ any person in any manner so as t0 ITE O ENGINEER TE
become subject to the Workers'Compensation LBWS. • CLASS
CADWETION / APT CONDO
Date Applicant D V CLASS NO. DWELL UNITS
NOTICE TO APPLICANT: If, after making this Certificate of C OR TEL NO. REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you Should become subject t0 the Workers' SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code,you must forthwith FRONT
LIC. O.
comply with such provisions or this permit shall be deemed revoked. PL _
�a/F6 SIDE ='�
LICENSED CONTRACTORS DECLARATION /p LIC.CLASS PL
I hereby affirm that 1 am licensed under provisions of Chapter 9 cz SEWER MAP 'R E
(commencing with Section 7000)of Division 3 of the Business and IFZTMLW NO.OF SORES NO. FAMILIES ;+-;r— c- ; �
NEW BK PG :3117 t15208'rFC-
Professions Code,a d my license is in full force and e�ct. IPTIO of ADD ❑ VALUATION ® i 1��E'� a
License Number �� Lic.Cla �j �j' d D �p �'°�•` �'
Contra QQ� � °- ALTER ❑ TOTAL
�•9 6 /� �7/ LREPAIR ❑ t�{{E4V�i �� ■ti?P
❑ I am exempt under Sec.
B.&RC.for this reason OL ❑ LOMA PIC# CHANGE =0 I
USE OF EXISTING BLDG. ❑
Date:
Signature Vmm-rHE;�IPPLICANTORFU....,
T(PRINT TE N LDMAPerm a Z IJ�II]!_I—jJ�I�� ?f1fi
❑ I,as owner of the property, or my employees with wages as
their sole compensation,will do the work and the structure is FINAL DATE Q i L f
not intended or offered for sale (Section 7044, Business and66� I 00.
Professions Code.) ILDING OCCUPANT HANDLEAHAZARDOU3MATERIAL �_` —I
J
�rI OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN 4
>L 1 1, as owner Of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE; FINAL BY 9
1` 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 THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST
FORGUIDELINES.
I hereby affirm that there Is a construction lending agency for
YES
❑ NO❑
the performance Of the Work for Which this permit Is issued(See. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD +° t t..s -�-- J.. r' r_,J
3097,CIV.C.. PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES .l L"�'i -T'-•" I'r'I '""') •�'
COUNTY CODE,TITLE2,CHAPTER 220 SECTIONS 220.100THROUGH 2.2MI40 CONCERNING 'moi i"', � �� 3?' '�•! --'J
Lenders Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. I.1JIJIL
F"•�• 1r-ILandrAddress OWIDORAiNi ,1
0 1 certify that I have read this application and state that the above FC.FEE PERMIT FEE
informatio corre gree to comply with all ounty p
o na and S I Iating to ildin construe n,an 6
h author) re e tiVBS is my to an r up ISSUANCE FEE -1:I :y 1•.4I Y_.J t•.!
above-me o d pro Insp " '� ' L,
p rty u IL I r_- C•
INVESTIGATION FEE TOTAL FEE D ' r)/ F, r e , r_-
.411—If
O�-I ••fes •�I•i L'� F..i N•.:s I•-=
SF�F,�.,EX�P����yy �A :gAGE