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HomeMy Public PortalAbout5423 ROSEMEAD BLVD_Building__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have certificateoof consent to self APPLICATION FOR ,BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, -car a certifiedcopy thereof (Sec. 3800, Lab. C.) C? 745 — ���M�*1 i COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. f7 Company _,,�j Certified.copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 542-3 BUILDING TiT 1(1 �C ❑ Certified copy is filed with the county building inspec- BUILDING Q CY^Eyt/ E (1 BLS –rmmpLs GTS( tion department. ADDRESS C �✓ 1���'"'K–''`"1/ GA Date �"'�7 Applicant CITY TPM PL–r= UT 1 ZIP ` LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE 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 A V TEL. 281_ 01 USE ZONE MAP I certify that in the performance of the work for which this OWNER A K T(J R k)F�'2L�, `NO. ✓ NO 2– _ permit is issued, I shall not employ any person in any manner ADDRESS I�ZJ, s ` I�`�MO QT 6�— CONDITIONS t so as to become subject to the Workers'Compensation Laws. (� Q U Date Applicant /I CITY AL+UkXA D P-4 CA ZIP 1 1301 � NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT G UP TYPE F E PROCES D BY NO. . Exemption, you should become subject to the Workers' ENGINEER CONSTNE 519 Compensation provisions of the Labor Code, you must forth- ADDRESS J' W with comply with such provisions or this permit shall be 5V//�� TEL. STATISTICAL CLASSIFICATIONN APT. rONDO. deemed revoked.' CONTRACTOR A NO. �2–�S� Z LICENSED CONTRACTORS DECLARATION �22w 1 Iry G–FF0 Z LICrp. / o57 CLASS NO. ZZ DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS `'/7 NO. O YO SEWER MAP (commencing with Section 7000)of Division 3 of the Business and L �Dt>�E LI . Professions Code, and my license is in full force and effect. CITY t CL BK '�' VALIDATION L p SQ. FT. NO.OF NO.OF CHECK License Numb aw�,�v Lic.Class SIZE STORIES FAMILIES ONE VALUATION i DESCRIPTION OF WORKNEW JX ;28.1 GO A Contractor ����D e ADD Elf tcS�©r ti0 I am exempt under Sec. GOroERCIAk— S1 G1J , #. 23 ALTER ❑ e ° ° ° B.BP.C. for this reason sILtGLE F>ACi� GH/�NN�(. A �-E� REPAIR E] $ d ,•,° ° 37.5,0 Date: USE OF DEMOL EXISTING BLDG. � _ APPLICANT TEL. °,,° ° 3 1,5 0 U Signature PRINT NO. FINAL .._. OWNER-BUILDER DECLARATION DATE � I Q 1 3 `8 7 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FA ;28J V A Professions Code): PRESENT BY aBUILDING # ° ° 0,0 *;J I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY ® I ° ° 49.8 8 the structure is not intended or offered for sale(Section 7044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO. ° ° ° 4 9.8 8 5 with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). ADDRESS Qi1 3;,6 g 7 CONSTRUCTION LENDING AGENCY SETT REQUIRED YARD HWY TOTALSETBACK 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. Lender's Name 3 LDMA Ref. # m P.C. Fee$ 3_1Permit feeLa Lender's Address i Poo g 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 oll'County Investigation Fee Q( S ordinances and State laws relating to building construction, Total Fee 0 LDMA Perm. # R and hereby authorize representatives of this County to enter upon the above-m ntionedproperty for inspection purposes. a / _ SEE REVERSE FOR EXPLANATORY LANGUAGE ^ Signature W Applica t or Agent Date .r F .��WgRKERS,COMPENSATION DECLARATION }. nt to insureboraafetrti'f cgte of Wo k�srtComipensatioof n eInsuran elf APPLICATION F®R BUILDING PERMIT or a+certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SA ETY Policy No. Company ❑ Certified copy is hereby furnished. FOR'APPLICANT TO FILL IN BUDDING ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS ;S'`l 23 � Date Applicant CITY V ��= `-'T zip LOCALITY L CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. CL' (This section need not be completed if the permit is for one ASSESSOR hundred dollars ($100)or less.) TRACT n �7BLO/C�K) LOT NO. MAP BOOK PAGE PARCEL OWNER �` OCgp L✓,\ry�1/`(t�J. NO. USE ZONE MAP I certify that in the performance of the work for which this NO. c2 } Ll permit is issued, I shall not employ any person in any manner G SPECIAL Det so as to become subject to the Wor s`Compensation Laws. ADDRESS 2� 1�1iC�►16��- CONDITIONS O (' Date %Z'X� _ CITY l �w� ��. `_►� ZIP U Applicant ARCHITECT OR -+ II TEL. NOTICE TO APPLICANT: If, aft king this Certificate of ENGINEER S�1 DISTRICT G���QQQUP TYPE FIRE PRO SED BY O Exemption, you should becom subject to' the Workers' i"�i NO. ` l CONST. y Z U Compensation provisions of the Labor Code, you must forth- ADDRESS )� J (/ v L+� with comply with such provisions or this permit shall be AJ TEL. STATISTICAL CLASSIFIC TION APT. C DO. N deemed revoked. SAP�1 v�_ rS NO e t,t r� CONTRACTOR Z LICENSED CONTRACTORS DECLARATION � LIC. 41cl(t$Z CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS f4 4 �`� n''r"I 'C NO. (commencing wLIC. 10 with Section 7000)of Division 3 of the Business and ---� SEWER MAP /� /�-_� Professions Code, and my license is in-full force and effect. CITY •1 l��- �.•++- CLASS � � BK 6 PG VALIDATION Q t1 �d k• SQ. FT. -L I a TNO, OF , NO.OF CHECK License Number t 8 2t�• Lic.Class SIZE ISTORIES FAMILIES ONE NEW VALLIATION Contractor �.tpJa�l SG^""�L9ote,/�• DESCRIPTION OF WORK Tt1l4I"t �.�`{ ® $ /"(fa 001 am exempt under Sec. iv�+hL�i .{ (Jfl bti.q..i.- ADD ❑❑ V , #:o 0 0 923 T ALTER h� B.BP.C. for this reason "f b�•+• I`gyp`� ^ "` �. REPAIR ❑ $ o 0 0USE F j 8 EXISTOING BLDG. DEMOL E] O 0,00—.05. "ticAPPLICANT TEL. Signature FINAL O ERBUILDER DECLARATION PRINT NO. DATE �7 6 8.3 / 1 hereby of r at I am exempt from the Contractor's License o a p Low for the following reason (Section 7031.5, Business and ADDRESS FINAL o 0 0 4� Professions Code): PRE E BY _ ❑ BUILDING n// O�,yi O rJ 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. ❑ I, 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 CONSTRUCTION LENDING AGENCY 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. Lender's Names z LDMA Ref. # m Lender's Address / P.C. Fee$ 3 11 Permit Fee 3 g I certify that I have read this application and state that the Issuance Fee Dc LDMA P/C H above information is correct. I agree to comply.with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee it LDMA Perm. N and er by authorize representatives of this County to enter m u m e above enti/ property for inspection purposes. 1 SEE REVERSE FOR EXPLANATORY LANGUAGE n Signature of Applicant or Agent Date