HomeMy Public PortalAbout6243 ROSEMEAD BLVD_Building__ *. APPLICATION POFD BUILDING PEISMIT
FOR APPLICANT TO FILL IN (Print or type only)
BUILD( G ) COUNTY OF LOS ANGELES
ADDRESS 3 g) a d j DEPARTMENT OF COUNTY ENGINEER
CITYT_e1j7A 6 Ctlig zIP BUILDING AND SAFETY DIVISION
%'� 13� NOW ON LOT .7 ADDRESS SJ,dj�1 LB 1 �L�
SIZE OF LOT r
TRACT J + r.�
(j`/ BLOCK / LOT NO. f�"7 LOCALITY
NEAREST
OWNER 0� �-rn C;JjL4.rZ NO. �[sLl3 / CROSS ST. Q y,
ASSESSOR
ADDRESS 3 yP JYj g�(� + MAP BOOK PAGE PARCEL
CITY DISTRICT YUP TYPE FIRE SSED B
R -L' CL ZIP D CONST - ZONE,
ARCHIT CT OR TEL. O4`► �- �`__, - (�
ENGINEER NO. STATISTICAL CLASSIFICATION SEWERA P
ADDRESS CLASS NO. �Z_I DWELL.UNITS BK PG
CONTRACTOR �� TEL.
NO. f &P.ZONELl
LIC.ADDRESS ' NO. IAL /
LIC DITIONS /
CITY CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES ❑ NO ❑
CONSTRUCTION LENDER
NAME AND BRANCH SETBACK FROM
FRONT PROP.LINE OF (STREET)
ADDRESS CITY TOTAL SETBACK FROM TYPE OF EXISTING
SQ.FT. NO.OF NO.OF CHECK HIGHWAY + YARD = FRONT PROP.LINE HIGHWAY WIDTH
SIZE STORIES FAMILIES ONE }
DESCRIPTION OF WORK NEW ❑ + O
ADD ❑ BLDG.SETBACK FROM
SIDE PROP.LINE OF (STREET) O
ALTER `DZ = TOTAL SETBACK FROM TYPE OF EXISTING b
i HIGHWAY + YARD SIDE PROP.LINE HIGHWAY WIDTH , N
USE OF REPAIR ❑ : Z
EXISTING BLDG. DEMOL ❑ +
APPLICANT TEL CORNER CUTOFF YES ❑ NO ❑
(PRINT) NO.
IN OPEN SPACE YES ❑ NO ❑
BY(SIGNATURE) IN COASTAL PERMIT ZONE YES ❑ NO
QQ ❑
VALUATION�P Z90 d� L��+•✓ -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES
AND LAWS REGULATING BUILDING CONSTRUCTION.I CERTIFY THAT IN DOING THE
WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF
THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COM-
PENSATION INSURANCE.
SIGNATURE O
PERMITTEE
ADDRESS
TEL. DATEL BY •�- -tom
CITY NO.
= MAKE CHECKS PAYABLE TO: F E FET
HARVEY T.BRANDY,COUNTY ENGINEER -
PLAN CHECK VALIDATION CK M.O. CASH m PERMIT VALIDATION 9' M.O. CASH
19 Pr--APR 2",8 :1 0 1. 6.0 U .
®s 76A638A CE#803 3.75' _
I
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANM FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self insure, BUILDI G D CM C�
I
d-a tG r--
or y there7f( of Workers'Compensation Insure cep a rtifi OITY ZIP f�� nn�- C_
copy thereo/f(Se 3(3 0 C.) (( LOCALITY
Policy No. ` Company SIZE OF LOT NO.OP BLDGS,NOW ON LOT
❑�ertffied
is hereby furnished. NEAREST CROSS ST.
y is filed with the cou ty building' s action TRACT BLOCK LOT NO.
de m
/I f USE ZONE MAP NO.
r�t��� J/�
Date �J Applicant (ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CE FICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO.
COMPENSATION INSURANCE [ti WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDRESS
m thy' DISTRICT GROUP FIRE ZONE PROCESSED BY
dollars($100)or less.)
CIT ( ZIP
I certify that in the performance of the work-for which this permit
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate of I ��) �L REQUIRED TOTAL SETBACK FROM EXIST
ExemCompensation roprov provisions ofbecome subject to the the Labor Code, you must Workers
h CONT C d'A Ali— SET BACK YARD HWY PROP LINE WIDTH
�/ FRONT
comply with such provisions or this permit shall be deemed revoked. ADDR ` Nva 3sb PL
/ L 7
LICENSED CONTRACTORS DECLARATION SIDE
cITY Lid.cuss P L
I hereby affirm that I am licensed underprovisions of Chapter 9 1SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZ NO.OF STORIES NO.OF FAMILIES }
Professions Code,and my licens is in full force and effect. Cj NEW ❑ BK PG ,
License Num er (' � Lic.Class r DESCRIPTI of WORK App ❑ VALUATION
n"
Contractor a e �� ALTER ❑ l V
ElI am exempt under Sec.
REPAIR $
BAP.C.for this reason A V c CC ett DEMOL ❑
SE OF EXISTING BLD� ( LDMA P/C#
Date: (( URM ❑
yco
Signature APP CANT PLANT) TEL NO. LDMA Perm# i z
❑ I, as owner of the property, or my employees with wages as V La •ry ` ` — Z r•;• a
their sole compensation, will do the work and the structure is ADDRESS10 e / O AC' T a a
not intended or offered for sale (Section 7044, Business and v l - C� �► d V N FINAL DATE a Vn- 139.��i j
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL —�6`��
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J •� T�E I
❑ I, as owner Of the property, am exclusively contracting 44, FINAL BY j a j�i L"
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE?
licensed contractors to construct the project (Section 7044, TOTAL
YES❑ NO❑ 1.4E F•AL 13$f� "•
Business and Professions Code.) �0
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CHECKCHECK�/, _c � l
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR
I GUIDELINES. 1 1,�
AN
I hereby affirm that there is a construction lending agency for I YES 11 No ElC' G 0
the performance Of the work for which this permit IS Issued(Sec. I I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
N 3097,CIV.C.) CHECKUST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE.
TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS
Lender's Name
I MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. if i `!•a
o Lender's Address �y{{
p OWNER OR AGENT 8-56 i ! i'M 12,:0,17,
i
o I certify that I have read this application and state under penalty
0 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE i
a II county ordinances and Sts laws relating to building
a• 9
� const uction, nd here authorize sentatives of this County ISSUANCE FEE
ato a er upo a ntioned p arty for inspection purposes �! g
m 7 INVESTIGATION FEE TOTAL FEE �f� Q O
r >�o um m AOW cr Awnt oma / O
SEE REVERSE FOR EXPLANATORY LANGUAGE