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Home My Public Portal About5729 ROSEMEAD BLVD_Building__ ��J `zc WORKERS' COMPENSATION DECLARATION ' � PPLICATION FOR BUILDING PERMIT I'hereb% affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. 6.) COUNTY OF LOS'ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING PY Y °„ADDRESS ❑ Certified copy is filed with-the county building inspec- BUILDING tion department. Date ESS Applicant CITY �-( ZIP LOCALITY Q (�( NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 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.) TEL OWNER' —NO USE ZONE MAP' I certify that in the performance of the work for which this NO* permit is issued,.)shall not employ any person in any manner ADDRESS # i SPECIAL CONDITIONS 01- so so as to become subject to the Wokkers'Compensation Laws. O CITY ZIP U Date rL Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE T A LICANT: If, after maki j,is Certificate of ENGINEER NO. ,Exemption, you should become subject to the Workers' - CONST. ZONE u Compensation provisions of the Labor Code, you must forth- ADDRESS ' "e ��' M with comply with such provisions or this permit shall be EL' p STATISTICAL CLA SIFICATPN APT. CONDO. Z deemed revoked. CONTRACTOR • ' s NO. 8- (oc _ LICENSED CONTRACTORS'DECLARATION LIC. w�f CLASS NO. DW�. UNITS I hereby affirm that I am licensed under provisions of.Chapter 9 ADDRESS (–( NO. SS LIC. SEWER MAP (commencing with Section 7000)of Division 3:of the Business and,Professions Code-,and my license is in full force and effect. CITY CLASS BK VALIDATION ee L� SQ. FT. NO. OF NO. OF CHECK License Number_ 0 no Lic.'Class SIZE STORIES FAMILIES ONE ` VALUATION Contractor 'Date DESCRIPTION OF WORK �A� NEW $ V�.'l ❑ Elsi I am exempt under Sec. - ADD ' ALTER ❑ B.&P.C. for this reason 661 REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. Z I hereby affirm that I am exempt from the Contractor's License DATE Law for the fol lowing'reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT B ❑ I, as owner of the•, ro ert or.m employees with BUILDING y P P Y. YADDRESS wages as their sole compensation,will do the work and :• r- the structure is not intended or offered for sale(Section LOCALITY ® h_-V! ":• _. - ' 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- ? .i t •, tion 7044,Business and Professions Code.) ADDRESS l REQUIRED TOTAL SETBACK FROM EXIST, i:,; ;-1• ;art;mss _ CONSTRUCTION LENDING AGENCY. SET BACK YARD HWY PROP. LINE WIDTH L I hereby affirm that there is a construction lending agency for FRONT -- c the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. _.iI:,_Er n;,r Lender's Name LDMA Ref. # ' P.C. Fee$ Permit Fee v � / - -- •- ••• ••• Lender's Address - - --. -• _: r`:%':: I certify that I have read this application and state that the Issuance Fee �� 7�'" LDMA P/C# , i above information is correct.•I agree to comply with'all County Investigation Fee ordinances and State laws relating to building construction, Total Fee// o O 11) LD MA Perm. # and hereby authorize representatives of.this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature oMppant or Agent Date • :'WORKERS' COMPENSATION DECLARATION I hereby affirm that I have certificate of consent.to self APPLICATION FOR 6ILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified coy thereof(Sec. 38 , L b C.) � COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No �orT�pgP N( M� �Lu _� BUILDING ,s��l ❑ Certi"ed copy is here y u ed. `3 FOR APPLICANT TO FILL IN ADDRESS C ❑ Certified copy is filed wi the ount"bu'fding inspec- BUILDING Mq tion department. ADDRESS Date v Applicant CITY " (f ZIP LOCALITY NO. OF BLDGS. NEAREST CERTIFI TE OF EX FRO WORKERS' SIZE OF LOT NOW ON LOT u CROSS ST. COMPE ATION 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.) OWNER NO.Offm 3' USE ZONE J.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 '7 (/ hAV E 4: /�.� SPECIALCL so as to become subject to the Workers'Compensation Laws. i CONDITIONS O CITY ZIP `A U Date Applicant ARCH O EL. DISTRICT GROUP TYPE FIRE -PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER �)t �. CONST. E 0 Exemption, you should become subject to the•Workers' ,�j{Ap `� '/ U Compensation provisions of the Labor Code, you must forth- ADDRESS o r ,�'6''1'J {� a with comply with such.provisions or this permit shall be t_In TEL y Q STATISTICAL CLASSIFICATION APT. CONDO. . Z deemed revoked. CONTRACTOR (�W .+ NO t5 _ LICENSED CONTRACTORS DECLARATION #4 LIC f�/y�^y CLASS NO. DWELL. UNITS ADDRES . Fi. ��I I�T I• ( � / NO.S+I Ti}S I I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP �•=� (commencing with Section 7000)of Division 3 bf the Business ,y and Professions Code,and my license is in full force and effect. CITY! At71"�► 1,, 1��?�CLASS f7 BK PG (jCf, XODATION a SQ. FT. NO.OF NO. OF CHECK (Y SIZE ��C/ STORIES FAMILIES ONE 1'i License Number J II ��) Lic. Class _,.,.t( Contractor) traChA� [-cR►f-. /((_ Date' %� v DESCRIPTION OF WORK NEW ❑ VALUATION ADD ❑ T.,. 3:; ❑1 am exempt under Sec. C 'f/' lro 'e ® ,I I�rt,_ _ �=s ALTER ❑ B.&P.C. foaso is n $ CHECK ?,L l USE OF REPAIR ❑ ate: EXISTING BLDG. DEMOL ❑ , "�l'T- t�{�t�J}= Signature0AI APPLICANT TEL, _ j g O - ER DECLARATION• (PRINT) �NO FINAL DATE I hereby off' t at I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL j Professions Code): !'t'i ! o'' PRESENT• By _.�,�.,= ...�;y�I I BUILDING ❑ I, as owner of the property, or my employees with ADDRESS '•` =s= 2; 1. '` wages as their sole compensation,will do the work and ``�t "–' s` s" the structure is not intended or.offered for sale(Section LOCALITY ® ':s^'` '1;=: 7044, Business and Professions Code.) MOVING TEL. " -- CONTRACTOR NO. r'HANGl: IL ❑ I,as owner of the property,am exclusively contracting .r>.:.:,•.,.. � � �_,. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.). CONSTRUCTION LENDING AGENCY SETBACK YARD 'HWY TOTALPROP. LINE SETBACK FROM " WIDTH I hereby affirm that there is a construction lending agency for FRONTyr 0:._ the performance of the work for,which this permit is issued P.L. . _ _ 4`ii:l= _: (Sec. 3097, Civ. C..). SIDE P.L: Lender's Name— . P.C. Fee$ Permit Fee LDMA Ref. # Lender's Address /,/ I certify that I have read this application and state that the Issuance Fee / LDMA P/C# above information is correct. I agree to comply with all County ". Investigation Fee Q ord nan sand tate law elating to building construction, Total Fee � ' / V LDMA Perm. # ' and ere y out orize re resentatives of this County to enter upo th a ove a tlorled property for inspection purposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE Stgn—ature'of Applicant or Agent Date t