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Home My Public Portal About6142 ROSEMEAD BLVD_Building__ lot 1. .76A638A CE#803 644 APPLICATION FOR •BUIL ING PE • T COUNTY OF LOS ANGELES' BUILDING DEPARTMENT OF COUNTY ENGINEER ADDRESS BUILDING AND SAFETY DIVISION LOCALITY r JOHN A. LAMBIE..COUNTY ENGINEER NEAREST - COLEMAN W. JENKINS,SUP•T.OF BUILDING CROSS ST. DISTWT 140. 2EI TYPE. SSED BY FOR APPLICANT TO FILL IN coNsr. J BUILDING 61+2 N. Rosemead Blvd. STATISTICAL ASSIFICATION SE EyR MAP ADDRESS O CL.ASQ NO. DWELL UNITS BKZ&>�G LOT No. i BLOCK USE ZONE MAP -NO.. TRACT i � SPECIAL N0. OF BLOBS, CONDI TIONS SIZE OF LOT NOW ON LOT USE OF BLDG. SETBACK FROM OWNER me S. rVln NOL' RRONT PROP. LINE OF _ ` TYPE OR EXISTINB SETBACK HIGHWAY Y D TOTAL ADDRESS6 2 Rosemead Blvd* HIGHWAY MCL. CITY Temple City, California + BLDG••eE BACK FROM • - ARCHITECT OR TEL. SIDE PROP. LINE OF (STREET) ENGINEER NO. TYPE OR EXISTING SETBACK HIGHWAY + YARD = TOTAL � ADDRESS HIGHWAY WIDTH FROM C.L. d CONTRALTO lgl o 'Co. NOL. o ' + = .0 ADDREss337 S. Woods Ave. NI' CORNER CUTOFF YES NO O V CITY CIC ; SEE REVERSE SIDE FOR SPECIAL APPROVALS W DESCRIPTION OF WORK y NEW ADD ALTER E AIR X DEMOLISH Z SQ.FT. Nd. OF NO. OF SIZE STORIES FAMILIES USF TRUC STUR dwelling SIGNATURE F I APPLICANT VALUATION$ 330-00 APPROVALS DATE INSPECTOR'S SIGNATURE ' FEE$ FEE'$ 6.00 FOUNDATFORMA,I MATERCAAI_SON 'FRAME, FIRE STOPS, 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLT AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS 9UILD CONSTRUCT[ I CE IFY TH . IN DOING THE WORK AUT ED HE •I WI EMPLO PER I ATH. INT. TIO F T R CO TA COMPENS 1 INSURANCE. LATH. EXT. SIGN T E !HOUSE NUMBER COR-• / PE4tMITTEE RE AND POSTED. ADDRESS I/// F1 NAL JOHN F. LEWIS. PRINCIPAL ST WURAL•ENGINE R PLAN CHECK VALIDATION CK. M.O. CASH _ PERMIT VALIDATION.' eK. M.O. CASH LCo,.8 10 3. 042 DEC 1.3 1 D 6.0 0,' 1 DEPARTMENTCOUNTY OF LOS ANGE ESAFETY BUILDING U ' L ® ING ' WM. J. FOX, CHIEF ENGINEER APPLICATION FOR APPLICANT TO FIIN FOR OFFICE USE ONLY LL DISTRIPT NO. PLAN CK,�]R REC.No. PE MIT NO. BUILDING ® �Q �+I��r � 4 ADDRESS C o � /`�17.Y F!`//'�If� COIL✓� r� R C LOCALITY (�^' EIVED BY DATE OFAPPL. ATE�IpSSyUED _ NEAREST /l J1✓�1�� CROSS ST. BUILDING o ADDRESS /e/3ej'sz-p egm0 OWNER [/C/N(' MAIL LOCALITY CAY 1,1_0!L9P� ADDRESS 7y CrD NEARESTTEL. CROSS ST. CITY NO. FIRE NO.OFTY GR UP ARCHITECT OR ® TEL ZONE I PLANS ^�/ r W ENGINEER ` NO. BLDG. ORO.• ® SETBACK LINE 710 ADDRESS USEAPPROVED ' TEL ZONE Ifj- BY DATE CONTRACTOR NO. HOUSE NUMBERING ADDRESS hM/AP NUMBER d� NO. ASSIGNEDLEGAL BY DESCRIPTION /LSOT NO. A x BLOCK /�[ �� CORRECTIONS/ c -` TRACT �/� �-d- �I;17 r`l / NO OF BLDGB. -57 ,) �" `�T,v/ ��/a�� SIZE OF LOT ei�0 �[ 6 I NOW ON LOT USE OF NO.OF EXISTIN BLDG. I FAMILIES" DESCRIPTION OF WORK 'S NEW ALTERATION ADDITION Z ,�/�J?t D • r REPAIR DEMOLITION SQ.FT. NO.OF / �� 16► SIZE :q ROOMS � STORIES EXT.WAL' ROOF �J COVERING „SY_C _eo COVERINGL/j%E22,j l P/dib UBE OFSTAR CTURE / xv ,roj - ;.^✓L� �6+,�r�:,c rye ��P& Al X Jf rEdgl A I cw ? C— �kwI . b n /.,/!,�►� 1�1>'. " �r+ti fir! -T ® o INSPECTION FOR 7 w APPROVALS OCCUPANCYAS INSPEOTOR'SSIGNATURE DATE FOUNDATION: LOCATION FORMS, MATERIALS �/� b I HEREBY ACKNOWLEDGE THAT I HAVE READ THISPLICATION AND STATE THAT THE INFORMATION GIVEFRAME: FIRESTOPS,CORRECT. BRACING, BOLTS1 AGREE TO COMPLY WITH ALL COUNTY ORDINANFURNACE: LOCATION, AND STATE LAWS REGULATING BUILDING CONSTRUCTppg VENT,DUCTS SIGNATURE OF [� LATH, INT.PERMITTEELATH, EXT. �i •�j�j �.i ADDRESS /// // y /• �r l PLASTER, INT. ! AUTHORIZED AOT. v'� PLASTER, EXT. 7 O O FEE s'O HOUSE NUMBER COR- �,.ar' FEE r RECT AND POSTED VALUATION v FEES .l �� FINAL �/j rK �-y7d ci�i' 76A638A 088 3 7-Si WORKERS'COMPENSATION DECLARATION1 hereG I insure, or a certificateirm that I of Workersve a 'CompensationsInsuranceificate of conent to , APPLICATION FOR BUILDING PERMIT or a certified copy thereof(Sec. 3800, Lab. C.) Policy No.AgZ2 y Company n,(� COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. 7,,)/',' R APPLICANT TO FILL IN BUILDING // / ADDRESS l/ (�e�� f I J!✓. s<1 Certified copy is filed with the county building inspec- BUILDIN /1 /tion department. ADDRES � Q S�-m� '7 �I�/J ` LOCALITY —/J f NEAREST Date `V Applicant CIN CL ZIP 917 d CROSS ST. CERTIFICATE OF EXEMPTI FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATIO NSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP hundred dollars ($100)or less.) TRACT BLOCK LOT NO. /J NO. • ''nn`` L/✓?f SPECIAL �- I certify that in the performance of the work for which this OWNER O r V ///�" [CONDITIONS 9L ermit is issued, I shall not em to an person in an manner DISTRICT GROUP TYPE FIRE PROCESSED BY O p P y y p $ADDRESS & I � CIS 0-*Me 0-4 r3 CONST. ZONE U so as to become subject to the Workers'Compensation Laws. (% -�CITY � �{, L ZIP `� �_ ✓ � �•� � Date Applicant STATISTICAL CLASSIFICATION " APT. CONDO. I.- ARCHITECT OR TEL. V NOTICE TO APPLICANT: If, after making this Certificate of �T '! AU ENGINEER NO. CLASS NO. DWELL.UNITS Exemption, you should become subject to the Workers' �. Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be deemed revoked. Qq BK, ' VALIDATION CONTRACTOR Sia. G O[ � LICENSED CONTRACTORS DECLARATION ` LIC. ry I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS &-& 6P('0_ NO. ��'2Dp2' VALUATION (commencing with Section 7000)of Division 3 of the Business and , LIC. e 3 j } /�Q 60 Professions Code, and my license is in full force and effect. CITY CLASS L $ .7 dZc �- SIZE S ORIIES FAMILLIIES CONE License Number -Cl 7 Contractor W•1.. yL- `�0% 94 //—/(0�� v t DESCRIPTION OF WORK NEW c $ ADD I am exempt under Sec. ALTER - FINAL 11,17_ eye REPAIR DATE / CJ G B.&P.C. for this reason Date: USE OF ° FINAL DEMOL EXISTING BLDG. ❑ By Signature APPLICANT TEL. OWNER-BUILDER DECLARATION PRINT NO. I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT( ❑ j I, as owner of the property, or my employees with BUILDING ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7 r%9 1 A 7044, Business and Professions Code). MOVING TEL. CONTRACTOR NO CONTR . I, as owner of the property,am exclusively contracting o 0 0 0 0 � with licensed contractors to construct the project (Sec- „ ADDRESS tion 7044, Business and Professions Code). ' ° o Ll 5 U(t REQUIRED TOTAL SETBACK FROMEXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH �: I hereby affirm that there is a construction lending agency for FRONT �� ` � L the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE o P.L. o Lender's Name yc � P.C.Fee$ Permit Fee Lender's Address I certify that I have read this application and state that the Issuance Fee ,9 S above information is correct. I agree to comply with all County Investigation Fee G/ ordinances and State laws relating to building construction, Total Fee and hereby authorize representatives of this County to enter upon the above megtioned prop fly for inspection purposes, w SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applican r Agent Date es j WORKERS'COMPENSATION DECLARATION � n I I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, APPLICATION F®RU,ILDINC9 PERMIT or epwied,copy hereof Sec: 3800, La C. . e& a`-/ �/7� • COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company �- Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS zlzla n_ Certified copy is filed with the county building inspec- BUILDING L=X tion department. ADDRESS Na-ca Date :J I Applicant �/ CITY { CZIP . LOCALITY ' CERTIFICATE OF EXEMPTION'FROM ORKERS' - NO.OP BLDGS. NEAREST: r COMPENSATION INSURAN E SIZE OF LOT NOW ON LOT CROSS.ST. (This,section need not be completed if the permit is for one ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL ijTEL. USE ZONE MAP I certify that,in the performance of the work for which this OWNER V NO.` NO. -.20L 3 permit is'issued, I shall not employ any person in any manner SPECIAL so as to become subject'to the Workers'Compehsation Laws. ADDRESS S �/ CONDITIONS V CITY. c` �' ZIP y td Date Applictint ARCHITECT OR TEL. CI NOTICE TO APPLICANT: If, after making this'Certificate of ENGINEER NO. DIS.TRICi.._ GROUP TYPE FIRE PRO ESSED Ezempyion, you should become subject to the Workers' CONS,T./ ZONE y Compensation provisions of the Labor Code, you must forth- ADDRESS �� with comply with such provisions or this permit shall be '•- deemed revoked.. NO., r p STATISTICAL CLASSIFICAT ON RAPT. CONDO. CONTRACTOR e�C� NO. 'LICENSED CONTRACTORS'DECLARATION' LIC; CLAS NO. ? DWELL. UNITS • I hereby'affirm that I am licensed under provisions of Chapter 9 ADDRESS ` � ei N � ��Yi (commencing with Section 7000)of e, O. Division 3 of the Business and i LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY V t c.\ CLASS BKS VALIDATION n� CE � SQ.FT.•.. STONO.OF FA OF _ CHECK., License Number �L I`'ti Lic.Class -� SIZE STORIES FAMILIES ONE VALUATION_ dC .J ` DESCRIPTION OF WORK "' NEW ❑': $ MC) Date 7 , ADD _ a I am exempt under Sec. ALTER / ., , B.BP.C. for this reason REPAIR $1 0 G u,6 A , Date: USE OF ^L 0 0 0 0 0 EXISTING BLDG. C DEMOL ❑ APPLICANT TEL. Signature r FINAL 2 a - 780 o ' OWNER-BUILDER DECLARATION PRINT) NO. O 'IG DATE I hereby affirm that I am exempt from the Contractor's License '7.� r , r t C O c Law for the following reason (Section 7031.5, Business and ADDRESS v 7 ' i FINAL _ Professions Code): PRESENT 'BY L� 0 J—8 4 F-1BUILDING I, as owner of the property, -or my employees with ADDRESS wages as their sole compensation,will do the work and 1Q So the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). 'MOVING TEL.' " DI,as owner of the property, am exclusively contracting CONTRACTOR NO. ' with licensed'contractors to-construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). ` REQUIRED TOTAL SETBACK FROM ST. CONSTRUCTION LENDING i4GENCY' SET BACK YARD HWY PROP. LINE WIDTH• I hereby affirm that there is a construction-lending agency for FRONT the performance of the-work for.which this permit-is issued P.L. - (Sec. 3097, Civ. C.). SIDE P.L. i Lender's Name P.C.Fee$ Permit Fee 7— Sa CDMA ERef. #L•ender's Address I certify that I have read this application and.state that theIssuance Fee �' CDMA # above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee "' CDMA Perm. # i and hereby authorize representatives of this County to enter upon the ab ve- entioned property f r inspection purposes. I cF Z,*A I SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of plic nt or Agent Date-• i WORKERS' COMPENSATION DECLARATION I hereby affirm that I have r cert Come of consent r self APPLICATION FOR �I 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.) i COUNTY OF LOS ANGELES BUILDING AND SAFETY ol•cy No.1 0 OZIR o Company 51-ATk -L,1,113 Certified co i hereb furnished. -FOR APPLICANT TO FILL IN BUILDING PY Y t ADDRESS I u Certified copy is filed with the county building inspec- ` ADDRESS TheLA —VvL-"tion department. "Sr- CITY i� Lt LUtD;,: ZIP PZ ^ j Date Applicant AO -�C,- cktJ LOCALITY' NO.OF BLDGS. g,NEAREST, CERTIFICATE OF EXEMPTION TROM WORKERS' SIZE OF LOT 7C L(D 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 ($100).or less.) TEL. OWNERpnN n WL NO. USE ZONE INO MAP I certify that in the performance of the work for which thisSPE permit is issued, I shall not employ any-person in any manner !x ADDRESS C, C-T fa'Y�Vt CONDITIONS so as to become subject to the Workers'Compensation Laws. O G CITY 1V�w.tG�-VLZ Wn ZIP U r. Date�n Applicant v •- v_ �V ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE TFED BY .NOTICE TO A PLI NT: If, after making this Certificate of "ENGINEER N0, 0 Exemption, you should become subject to the Workers' >. ' % 00 __31 � CONST. V Compensation provisions of the Labor Code, you must forth- :.ADDRESS ��// a with comply with such provisions or this permit shall be F: c,,- l TEL G 7 TATISTICAL CLASSIFICATION APT. CONDO. "N deemed revoked. ,'•CONTRACTOR C-C NO. IIA) 0 `�), Z LICENSED CONTRACTORS-DECLARATION LIC. O j Z CLASS'NO. DWELL:UNITS A. I hereby affirm that I am licensed under provisions of Chapter 9 `ADDRESS 6 G_ Ca NO. 6 CdU (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY CLASS BK. PG. VALIDATION If SQ. FT* NO.OF NO.OF CHECK License Number SJ$(A z Z Lid. Class SIZE STORIES FAMILIES ONE h�D✓_. r NEW ❑ VALUATION Contractor- L� '�� Q:---J Date DESCRIPTION OF WORK 'v $ . ADD ❑ Elam exempt under Sec. l uv�/ ' jALTER ❑ 8.8P.C. for this reason REPA ❑ $ Date: ,-USE OF p EXISTING BLDG. Lq L-r— DEMOL Signature , v ` �� c APPLICANT t �` .tj TEL. FINAL OWNERLA -BUILDER DECRATIO f (PRINT) _ Tv NO• `�a9k DATE I hereby affirm that I am exempt from•the Contractor's License Low (,t-�ItVry IIVLv7�T�sYL j �?H'` Law for the following reason (Section 7031.5, Business and . AL Professions Code): PRESENT By❑ . BUILDING �� ea I, as owner of the property,' or m •employees ees with ADDRESS -+:�-� 60.50wages as their sole compensation,will do the work and ® 3++ 7 the structure is not intended or offered for•sal4(S.ectioh LOCp`LITY i ITEMS 7044; Business.and Professions'Code.) MOVING TEL. ❑ I;as owner of the property,am,exclusively contracting CONTRACTOR' NO. TOTAL 60-50 with licensed contractors to construct the project-(Set- D R tion 7044, Business and Professions Code..) ADDRESSE CHECK �( �e CU(j REQUIRED TOTAL SETBACK FROM EXIST.' t CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH t1EiANGE ,00 1 hereby off irm.that there is a construction lending agency for FRONT the performance of'the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE, PA.- 11/ 9/89 Lender's Name iJ it S P. Fee$ Permit Fee i 00 LDMA Ref.#• 6679 1 AM10'132 Lender's Address 50. I certify that I have read this application and state that the Issuance-Fee r LDMA P/C# above information is-correct. I agree to comply with'all County Investigation Fee ordinances and State laws relating to building construction, I Total Fee � LDMA perm. # and hereby authorize representatives of tliis County to enter ( x upon ov -mentioned property for inspection purposes. I A � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or'Agenk, Date WORKERS'COMPENSATION DECLARATION I herel5y off rrm tkat I have a certificate of consent to selfL I CTION ®� �I L®IPERMIT .• insure, or 7 certificate of Workers.' Compensation Insurance, o`,a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Polity No.1ooS Company S7flTF_ /V r� / •,� ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ''BUILDING � � ��v ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING / r� - tion department. J ADDRESS (!/l 2— l �>✓� d �/l/ PL C—S X90 Applicant �—*�" _ C �itTy : CITY :r-- 6T ZIP LOCALITY � Ll. l X 16 3 NO. OF BLDGS. NEAREST CERTIFICATEOF EXEMPTION FROM WORKERS' SIZE OF LOT . NOW ON LOT CROSS,ST. COMPENSATION INSURANCE p ,�ASSESSOR (This section need not be completed if the permit is for one TRACT B BLOCK LOT NO. 0 MAP BOOK PAGE PARCEL hundred dollars ($100)or less;) OWNER NO. USE ZONE MAP. 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 CL so as to become subject to the Workers'Compensation.Laws. y� O CIN '• Q L` ZIP V Date Applicant ARCHITECT OR TEL. DISTRICT G OUP TYPE FIRE PROCESSED.BY NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER L NO D. 3'3D O Exemption, you .should become subject to the Workers' ''ll CONST. E17) Compensation provisions of the Labor Code, you must forth- ADDRESS, '(D — (/� . p„ with comply with such provisions or this you shall be TEL• -`STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. Q DWELL. UNITS I hereby affirm that I am licensed unLIC. provisions,of Chapter 9 ADDRESS NO. ' »SEWER MAP (commencing with Section 7000)of Division 3 of the Business � • and Professions Code,and my license is in full force and effect. CITY CLASS BK 23 VALIDATION /�� SQ. F7./��77��►►,� NO OF ^� NO.OF CHECK License Number Lic. Class SIZE (S" STORIES pL FAMILIES ONE �''��A D DESCRIPTION OF WORK NEW y VALUATION Contractor AW"I1f Q Q11� Date T v $ �/ 3W7 i e rt a ADD ❑ ® t, ❑I am exempt under Sec. 1 ITEMS ALTER ❑ '• BAP.C. for this reason USE.OF OWREPAIR ❑ $. TOTAL 5 3-2 m 55 q �Date: EMSTIING BLDG. DEMOL 1:1 �(� J r d V CHECK 512.55 JLA4 Signature - � J APPLIC(PRANT NO FINAL / :9 CHANIGE ■ 111 OWNER-BUILDER DECLARATION 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 /Q_ tin �,n Professions Code): PRESENT' By �l/% 010010-0ti01 p9L./�14/8 BUILDING fir,!1Q 1 A L11 ❑ 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 (1� 7044, Business and Professions Code.) MOVING TEL. ACC °3 -� n 1� ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. 33 7 1i . with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) r 1 ITEMS PP.C. IRED ,YARD HWY TOTAL SETBACK FROM EXIST. j t/ ,j CONSTRUCTION LENDING AGENCY ACK PROP. LINE WIDTH (� TOTAL 1-112..+ I hereby affirm that there is a construction lending agency for T V ®N the performance of the work for which this permit is issued CHECK. 1?1�-i?7 (Sec. 3097, Civ. C.). r CHANGE ei31 S Lender's Name S � LDMA Ref. # $ _ Permit Fee Lender's Address j (� 1]000-1]01111 411. SPE li I certify that I have read this application and state that the 1 Issuance Fee LDMA P/C# ® �,y� f, above information is correct.I agree to comply with all County Investigation Fee 9912 1. AM }`°•- 3 .ordinances and State laws relating to building construction, Total Fee LDMA perm. # and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signatureo Applicant or Agent Date ' WORKERS'COMPENSATION DECLARATION o� connt'to self insure,or 4 certificate of Worke s'tificate Compensaf on Insurance, APPLICATION FOR BUILDING P E RM I T or.a certified copy thereof(Sec. 3800, Lab. C.) DSTATE f=UN�� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company E:1 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILD D C� 5 c 13t-ly JD ❑ Certified copy is filed with the county building inspec- BUILDING L.V' tion department. /6.T zip LOCALITY�. ' d q ?t:&V CITY c �7 13 Date Applicant / k6 1 NO.OF BLDGS. NEAREST )x� CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT *:?'.• NOW ON LOT CROSS ST. COMPENSATION INSURANCEASSESSOR (This section need not be completed if the permit is for one j,TRACT BLOCK LOT NO, MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) OWNER — y (/d� , NO. USE ZONE MAP I certify that in the performance of the work for which this NO. < SPECIAL >_ permit is issued, I shall not employ any person in any manner ADDRESS , r KtJ CONDITIONS a- so as to become subject to the Workers'Compensation.Laws. Ts�j� OO CITY 4y l-A �y ISI ZIP /�T x Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER (' k) AKC�yr� 9oL. v CONST. E 0 Exemption, you should become subject to the Workers' , Compensation provisions of the Labor Code, you must forth- ADDRESS D '�. '`/f 1i�� 'or 93 � a with comply with such provisions or this permit shall be ` TEL STATISTICAL CLASSIFICATION A . CONDO. N deemed revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force an effect. CITY CLASS BK PG VALIDATION �jSQ. FT NO.OF NO.OF CHECK License Number " (4 Lic. Class SIZE 20, Lt' STORIES C FAMILIES ONE n /� VAI UATIONr��7 Contractor. LAD� 1 1 Date /V DESCRIPTION OF WORK NEW $1 v r/�vs El am exempt under Sec. / Sz/vr7 � ADD ❑ _ � ALTER ❑ B.BP.C. for this reason DG11ftslREPAIR ❑ 'i $ Date: USE OF p I - Z_/J-16 _ EXISTING BLDG. DEMOL ❑ Signature LJV/ Z_ 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 s FINAL_ Professions Code): PRESENT By J(r ❑ I, as owner of the property, or m employees with BUILDING Ai;CLT P P Y� YADDRESS wages as their sole compensation,will do the work and �= the structure is not intended or offered for sale(Section LOCALITY rj� �=►�e�t x834"�'' 7044, Business and Professions Code.) MOVING TEL. ITEMS ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS ((�� TI�I AL 1834.75 tion 7044, Business and Professions Code.) V �� -+� REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. C.-'HECK 1}34s 1•-s CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT CHANGE the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE 00 P.P.L. 00130-01001 4% 5/0 Lender's Address Lender's Name, P.C. Fee$ Permit Fee 0a I •�� M°`Ref. # 9931 1 AM 9:51 t I certify that I have read this application and state that the Issuance Fee 0, 00 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 J LDMA Perm. # and hereby authorize representatives of this County to enter upon the above-mentioned property for inspectionpurposes. i —12-L ver l V ' U �J SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date