HomeMy Public PortalAbout5629 ROSEMEAD BLVD_Building__ APPUCAM ' F BUILDING IT �1
_ COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate
ADDRESS
icate of consent to self insure,
or a certificate of Workers'Compensation Insurance,or a certified CITY ZIP
copy thereofJ(Seo.980,Lab.C.)
LO
Policy No. 1 i �Z Compa y �r--V AD C(. QALLEY
..,/ SI E OF T NO.OF BLDGS.NOW ON LOT NEAREST CROSS ST
L�Certl ied copy Is hereby fumis ed.
❑ Certified co lied wit t u y Ing Inspection TRACT BLOCK LOT NO.
dope ent., USE ZONE MAP NO.
Date
do
ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ' TT�EL No. YES NO
COMPENSATION INSURANCE �� � 6^A-0--Q—U WITHIN 1000 FT.OF SCHOOL?
ADDRESS
(This section need not be completed if the permit is for one hundred j glop DISTRICT "GROUP TYPE CONST.' FIRE ZONE PROCESSED BY
dollars($100)or less.) CITY .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. d
become subject to the Workers'Compensation Laws. •I?-- STATISTICAL CLASSIFI ATIOI� APT CONDO
Date Applicant gDDRfaSS CLASS NO. �1T5
NOTICE TO APPLICANT.• If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
qpVrRAExemption, you should become subject to the Workers' �iOR TEL. O.\f,-` SET BACK YARD• HWY PROP LINE WIDTH
Compensation provisions of the Labor Code,you must forthwith ' x� S�( —'`�
comply with.such provisions or this permit shall be deemed•revoked. AD SS LIC.NO. FRONT
MS b^i i W4TcY i2:!&vo PL
{ SIDE O.
LICENSED CO RACTORS DECLARATION t;ITY LIC P U,
icensed under provisions of Chapter 9 (� SEWER MAP
(commencing 'th 1 of Division 3 of the Business and SO.FT.SIZE NO.OF STORES ' NO.OF FAMILIES
Profession In full force and effect. NEW BK PG
DESCRIPTION OF WORK ADD ❑
License Nu Lic.Class VALUATION .
Contractor Date qS L(i �` ALTER ❑ A-700—� Z
❑ 1 am exempt under Sec. A If REPAIR ❑ $
B.B,P.C.for this reason �i�1 Ftp DEMOL ❑
Date: USE OF EXIST NG LDG. ,{� URS ❑ LDMA P/C N
`r— 2-1
Signature APPLICANT(PRINT) O. LDMA Penn#
❑ I, as owner of the property, or my employees with wages as �� ( 3 ®
their sole compensation,will do the work and the structure Is ADR
not intended or offered for sale (Section 7044, Business and FINAL DATE
Professions Code.) WILLTHEAPPLICANTOR FUTURE BUILDING OOCUPANTHANDLEA HAZARDOUS MATERIAL a. Z J L
❑ I, as owner Of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN
Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project.(Section 7044, YES❑ NOU
Business and Professions Code.)
IFODE
USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
REOUI APERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY OU_ MANAGEMENT IS,
(SCAOMD)SEE PERMITTING CHECKLIST ti i.I E:•«
JNES.I hereby affirm that there is aconstruction lending agency for N !l!iAli_ ` =:5 Kthe performance of the work for which this permit Is issued(Sec. HAZARDOU TERIALS IN TION GUIDE AND THE 3CAOMD �- "T•3097,Civ.C.. _ i= ',_J
IST.I UN AND MY REOUIR ENTS UNDER THE LOS ANGELES
ECTIONSaMEr.500THROUGH 220.140 CONCERNING -
�3i
Lenders Name SPORTING ERMIT FROM TFiESCAOMD.
4info
ddOVMer ��
o' at I h read this application and state that the above
Q P.0 FEE PERMIT FEE Kt-, ,w t +•• + ;-•
cqBrS is rrect. I agree to comply with all county _ -f �� l,E•i ;,;—I�•>»iE3;( ,,,dating to building construction,and �` 4^nta�t of this County to enter upon ISSUANCE FEE f= "•TN tion props nspection purp �M,.•,.� r„
maz
INVESTIGATION FEE TOTAL FEE '
r
E4InM=0fApp9 WAgNt .
SEE REVERSE FOR EXPLANATORY LANGUAGE