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Home My Public Portal About5636 ROSEMEAD BLVD_Building__ •_U/61RKERS'COMPENSATION DECLARATION j ,,Insure,hereby certif carte of Worke s'tCompensat on Insuranceent to , A P® L I C AT I®N F O R BUILDING P E RM I T s or a certified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company copy - BUILDING Certified cois hereby furnished. FOR APPLICANT TO FILL IN ADDREss ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS //��r -/7JLv� LOCALITY NEARE Date Applicant CITY: IL' Com/ ZIP g1 / �D CROSS S !9i/'1�/ T. CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. -ASSESSOR COMPENSATION INSURANCE Y SIZE OF LOT U NOW ON LOT MAP BOOK PAGE PARCEL USE ZONE MAP (This section need not be completed if the permit is for one 1 G v (r1 hundred dollars ($100)or less.) is TRACT Ap 0 BLOCK �p LOT NO. NO. TEL. SPECIAL �• I certify that in the performance of the work for which this OWNER ac. NO.v ��-79 TIONS �� 30 / DISTRICT GROUP TYPE FIRE PROCESSED BY permit is issued, I shall not employ any'C Pin any manner /7 / A CONST. ZONE s.� DG . so as to become subject to the Wor, rs'C ens 'on Law ADDRESS /� ✓G 7/5 /J� � II ,. irr (� zip 917Zen Date Applicant y STATISTICAL CLASSIFICATION APT. CONDO. NOTICE TO APPLICANT: If, after making this Certificate of I ARCHITECT OR TEL. r: ��JJ //JJ _ U Exemption, you should become subject to the Workers' ENGINEER b NO. CLASS NO.�WELL.UNITS FI Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be ,.l TEL, VALIDATION deemed revoked. CONTRACTOR }'�(��v NO. BK• PG, LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION 6� (commencing with Section 7000)of Division 3 of the Business and LIC. �j p� Professions Code, and my license is in full force and effect. CITY CLASS $ `/� (t l/d ► SQ. FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE ISTORIES FAMILIES �) ONE DESC PfION OF WORK /EQGCC/ S (�ya NEW ❑` $ I; Contractor Date a - ADD ❑ ❑ I am exempt under Sec. ALTER FINAL B.&P.C. for this reason Alk 7—#/-s - 5 &14,5_ REPAIR ❑ DATE USE OF / FINAL Date: EXISTING BLDG. [; v DEMOL ❑ By I �-• Signature APPLICANT / n�` TEL. ' PRINT �i /T(.. _ NO.�i� " OWNER-BUILDER DECLARATION - 0 5 � A I hereby affirm that I am exempt from the Contractor's License } /� n ' � Low for the following reason (Section 7031.5, Business and ADDRESS !afl/ 77C ` 4 Professions Code): e,PRESENT BUILDING I, as owner of the property, or my employees with ADDRESS ? - 511, 00 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY t q(]Q o "L'.(� 0 cs> 7044, Business and Professions Code). MOVING TEL: NO• 10 IJv2 ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. 1. CITY OF TEMPLE CI A (l'0 0-08 with licensed contractors to construct the project (Sec- ADDRESS PLANNIPdG DEP 1� p�T 'tion 7044, Business and Professions Code). I` ARTME REQUIRED TOTAL SETBACK FROM EXIST. APPROVED CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I� I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which h this permit is issued P.L. ' THIS APPROVAL IS CONTINGENT UPON THE FRCT.4 tSec. 3097, Civ. C.). SIDE I SUBMITTED AND THE REQUIREMENTS OF CITY ZONING // P L ORDINANCES IN EFFECT AT THIS TIME IT IS m �Q�/� A.P OCABLE ONLY AS SPECIFICALLY INDICATECI Lender's Name Ci' HEf0t'A,'qD&4YST BE USED PRIOR TO ANY CHANGE P.C. Fee$ Permit Fee — .IN PEARINE;J.T. €1F DINANCE REQUIREMENTS. SUCH. Lender's Address y4P}aAfOtR1L SHxsL N > / r f NOT BE CONSTRUED TO PERMfT I certify that I have read this application and state that the Issuance Fee Q TINE '�fOLATION OF APL1F pROVISIO 0 ANY COW above information is correct. I agree to comply with.all County Investigation Fee *F&PMAXE QIA STATE LAW ordinances and State laws relating to building construction, Total Fee �— and hereby authorize representatives of this County to enter upi thea ove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ®s • WORKERS'COMPENSATION DECLARATION fs I he affirm that I have a certificate of consent to self APPLICATION FOR BUILDING P E RM I T insure, or a certificct of Workers' Compensation Insurance, or a certified copy t)tereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ' BUILDING ' e ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN j,ADDRESS r3 A4 c4 E'f, ElCertified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 1j. ; Tel. CIN T T ZIP St? LOCALITY Date Applicant NO.OF BLD S. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 22Z NOW ON LOT CROSS ST. COMPENSATION INSURANCE , ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) r TEL. USE ZONE MAP I certify that in the performance of the work for which this ` f NO. 2 � permit is issued, I shall not employ any person in any manner ADDRESS 3 t0 C 3 SPECIAL CONDITIONS so as to become subject to the Workers'Compensation Laws. J �./� O CIN ZIP 3 , Date Applicant ARCHITECT OR TEL. W NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP OPE ZONE PROCESSED BY O Exemption, you should become subject to the Workers' /y�' Compensation provisions of the Labor Code, you must forth- ADDRESS S.cs� �� 3 ��',vf a with comply with such provisions or this permit shall be TEL•Zpp . ". STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR �7! J�1S NO. GY — LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 2`2-- DWELL.ADDRESS NO. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. NO. OF N_0. 0 F CHECK License Number Lic. Class SIZE STORIES IFAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW $ ❑I am exempt under Sec. ADD ❑ ALTER ❑ BAP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLD ( S DEMOL ❑ Signature APPLICANT TEL. g OWNER-BUILDER DECLARATION (PRINT) // NO. / DATE` , I hereby affirm that I am exempt from the Contractor's License ADDRESS /�1'l b/' / Law for the following reason (Section 7031.5, Business and FINAL Professions Code): PRESENT By taG'•:i o a ❑ BADDRESSUILDINGI, as owner of the property, or my employees with d?,311Df wages as their sole compensation,will do the work and the structure is not intended or offered for saleSection LOCALITY ® 4 G f , 7044, Business and Professions Code.) ( MOVING TEL. Il`sem -�-,�❑ s. ,,� --� t=I,as owner of the property,am exclusively contracting CONTRACTOR NO. ® �_s with licensed contractors to construct the project (Sec- ADDRESS `J�` CHECK 4,tion 7044, Business and Professions Code.) t:H i K `F3,f 5 REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH ANE 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. I,")I3l_10–1,001 Lender's Namei e S P.C. Fee$ Permit Fee ~7S LDMA Ref. 0 -7 7. 1 hili _ Lender's Address I certify that I have read this application and state that the Issuance Fee 3 �v V `DMA P/C 11 above information is correct. I agree to comply with all County Investigation Fee 7 J7 ordinances and State laws relating to building construction, Total Fee �!/�' LDMA Perm. ## and reby authorize representatives of this County to enter > ; up the ve do property for inspe flon purpose SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date '