HomeMy Public PortalAbout5633 ROSEMEAD BLVD_Building__ WORKERS' COMPENSATION DECLARATION
hereby affirm that I have certificate of consent self APPLICATION F O R 11 I L D I N
iry;�ire, or a certificate of Workers' Compensation Insurance,
ance, �
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING A
Policy No.1 0 8 5 13 2 Company STAT'F. FTTNT) BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 0633 I11.
❑ Certified copy is filed with the coun building inspec- BUILDING 5633 N. ROSEMEAD BLVD.
tion department. ADDRESS
2/22/96 CITY TEMPLE CITY ZIP LOCALITY
Date Applicant NO.OF BLDGS.
CERTIFICATE OF EXEMPTION FROM ORKERS' SIZE OF LOT NOW ON LOT NEAREST LAS 'PUNAS
CROSS ST. ir
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is f r one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) OWNER JAMES SAMPSON Nk055-239-4 713 ZONE MAP
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL a
so as to become subject to the Workers'Compensation Laws. CONDITIONS O
CITY ZIP
Date Applicant ARCHITECT OR TEL �
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO DISTRICT GROUP TYPE FIRE PRO BY O
Exemption, you should become subject to the Workers' S� 7
P Y I �� C04iN Z w
Compensation provisions of the Labor Code, you must forth- ADDRESS a
with comply with such provisions or this permit shall be c TEL• o '333 STATISTICAL CLASSIFICATION APT. CONSO. N
deemed revoked. CONTRACTOR SIGN EXE RE'SS NO, G43.3�J Z
LICENSED CONTRACTORS DECLARATIONLIC c:p CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 2446 ME,RCED AVE.-- NO. -��2097
SEWER MAP
(commencing with Section 7000)of Division 3 of the Business CIT, SO. EL 1`d011 TE
LIC SEWER
C�.-;�
and Professions Code,and my license is in full force and effect. BK. PG. VALIDATION
License Number Lic. Class
552097 C45 SQ. Fr.
STORIES FAMILLIIES ONE K
�I VALUATION
Contractor
,, SIGNS EXPRES- 2/22/96 DESCRIPTION OF WORK NEW � $
E]I am exempt under Sec.
ILLUM. CHANNEL LE`�TERS ADD ElpoolALTER 1-1
B.B,P.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL• ,• - J3 r; FINAL
OWNER-BUILDER DECLARATION (PRINT) SIGNS EXPRESS 4
S NO, 3 O �
DATE
I herebyaffirm that I am exempt from the Contractors LicenseSAME -AS3 Z��
Law fothe following reason(Section 7031.5, Business and ADDRESS ABOVE, FINAL 23
Professions Code): PRESENT BY
El1, as owner of the property, or my employees with ADDRESS ACCTo4
wages as their sole compensation,will do the work and , 3303 50.50
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL. 1
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. n v
1t
with licensed contractors to construct the project (Sec- ADDRESS ACCT.
1[r
7044, Business and Professions Code.) 3303 92025
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROPLIINEFROM WIDTIi
I hereby affirm that there is a construction lending agency for FRONT 2 ITEMS
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE TOTAL 142 o 75
P.L.
Lenders Name �+ CHECK 142075
B P.C. Fee$ Sf�. Permit Fee 60-61 Ref.q CHANGE .00
o Lender's Address ��^^ I;
1 certify that I have read this application and state that the Issuance Fee 2 •.7i.J LDMA P/C N Poo
above information is torr 1 agree to comply with all County Investigation Fee 0000_0001 2 22/96
ordinances and State I relating to building construction, Total Fee jee7 r. LDMA Perm. #
s.p.
and hereby thorize re entatives of this County to enter 4983 1 EH 6:10
upon th ob ve-mentio d p erty for inspectio pure ses,
o �� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App c nt or Agent Date