The URL can be used to link to this page

Home My Public Portal About5110 ROSEMEAD BLVD_Building__ WORVZ 'COMPENSATION DECLARATION ' p x='I hereby affcertithat I haver certificate of consent to self APPLICATION FOR BUILDING PERMIT N `i- iJ�sure, or a certificate of Workers' Compensation Insurance, br a cegified copy thereof (Sec. 3800, Lab. .k' Policy No. Company BUDING COUNTY OF LOS ANGELES BUILDING AND SAFETY r IL D Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS f X,.,/ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS j ( LOCALITY NEAREST l Date Applicant CITY ! ti( � ZIP 4 ) �' CROSS ST. } NO. OF BLDGS. ASSESSOR CERTIFICATE OF EXEMPTION U.RA WORKERS' SIZE OF LOT NOW ON LOT MAP BOOK PAGE ]PARCEL d COMPENSATION INSURANCE (This section need not be completed if the permit is for one __..,,LL�� USE ZONE MAP _ U hundred dollars ($100)or less.) TRACT T r— tt[�_K ' LOT NO. NO. LU TEL. _ Z, SPECIAL certify that in the performance of the work for which this OWNER Y % NO. CONDITIONS ti permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY so as to become subject to the Workers'Compensation Laws. ADDRESS ( r CONST. ZONE OC CITY j; y ZIP -( / Date Applicant ST IS ICltCCLASSIFICATION y NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL. UNITS Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP H with comply with such provisions or this permit shall be deemed revoked. - TEL. CONTRACTOR NO. BK PG VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm thct I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and i LIC. Professions Code, and my license is in full force and effect. CITY CLASS SQ. FT. NO. OF NO. OF CHECK , License Number Lic.Class SIZE STORIES FAMILIES ONE NEW Contractor Date DESCRIPTION OF WORK S I am exi4l.ipt under Sec. ADD ALTER FINAL B.BP.C: for this reasonDATE REPAIR Date: USE OF FINAL EXISTING BLDG. DEMOL B Signature APPLICANT TEL. Y OWNER-BUILDER DECLARATION PRINT - NO. I he[`eby affirm that I am exempt from the Contractor's License pop the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT ❑ BUILDING r,, 7 4 A 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 7044, Business and Professions Code). MOVING TEL. TOR NO RAC . n I, as owner of the property, am exclusively contracting CONT =; + with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). ADDRESS ry REQUIRED TOTAL SETBACK FROM EXIST #M CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 11011. ' ry p I hereby affirm that there is a construction lending agency for FRONT 7' C the performance of the work for which this permit is issued P.1. (Sec. 3097, Civ. C.). SIDE m P.L. Q Lender's Name P.C. Fee S Permit Fee Lender's Address I certify that I have read this application and state that the Issuance Fee ' above information is correct. I agree to comply with all County Investigation Fee S ordinances and State laws relating to building construction, Total Fee u and hereby authorize representatives of this County to enter Q upon the above-mentioned property for inspection purposes. m d a SEE REVERSE FOR EXPLANATORY LANGUAGE 0 Signature of Applicant or Agent Date ©$