The URL can be used to link to this page

Home My Public Portal About5741 ROSEMEAD BLVD_Building__ WORKERS' COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self AP L I CATION F®R ��U I L®I N G P E RM I T insure, or a certificate of Workers' Compensation Insurance, 1 or 6%tertified copy thereof,(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING ❑ .Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑• .Certified copy is filed-with the county building inspec- BUILDING �) tion department. ADDRESS Date' Applicant CITY ZIP LOCALITY pp 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.)• T OWNER USE ZONE MAP I certify that in the performance of the work for which this 11 SPECIAL//�� NO. permit is issued, I shall not employ any person in any mann r ADDRESS Q C/�� CONDITIONSck- so as to bec' e s bject to the Wor �11 /'�� ' CIN ZIP U Date4�eApplicant . ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE P CESSED BY 0 NOTICE 1b APPLICANT: If, after making ENGINEER NO. CONST. Z E Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- r' ADDRESS 0_, w a with. comply with such provisions or this permit shall be• TEL• p�r�+� STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR171� Z LICENSED CONTRACTORS DECLARATION A� /„, LIC. CiASS NO.:_DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS a�7irC� NO. SEWER MAP —" (commencingwith Section 7000 of Division 3 of the Business LIC. ) �/ CLASS 3t-`�-VALIDATION Prof�ssions Code,and my license is in full force and effect. CITY BK. PG, � NZ- �• SQ: FT. NO. OF NO. OF CHECK ;,F ^te Li ens Number J ��0 Lic. Class SIZE , STORIES FAMILIES ONE -'1° 'T'-i°�-' .� VALUATION ., -•-J.,• Contractor �'y �s _L�ateJi" ` DESCRIPTION OF WORK � 41%121 NEW / /� i i LI`s,; �/ ADD ❑ $ `c/`�`r �� ® ,-.•�H.L 4- 8 __ c: ❑1 am exempt under'Sec. ALTER El +' 7= B.BP.C. for*this rea $ �� 'USE OF REPAIR ❑ t•I'3rA*.NIG T' EXISTING BLDG. f' DEMOL ❑ APPLICANT TEL. Sign r- _ FINAL OWNER-BUILD CLARATION (PRINT) i NO. DATE 1 �(//jj�/f `+�;"y1 "r f` 'r•� tp I hereby affirm that I am exempt from the Contractor's License _f,i _ _C F Law for the following reason (Section 7031.5, Business and ADDRESS len FINAL _:i'O . „ sins.. Professions Code): PRESENT By BUILDING'• ❑ I, as owner of the-property, or my employees'with ^ADDRESS -wages as their sole compensation,will do the-work and LOCALITY 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. with'licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. 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 Pm Ln (Sec. 3097, Civ.'C SIDE i"` ' ' `•^ Frr ".; r. 3.KC a:l' ' a�A .n 3 Lender's Named LDMA Ref. # ^ � -L:• 4 P. Fee$ "7&41 /� Permit Fee �/ ' 0 ' C J---: Lender's Address I certify that I have read this application and state that the Issuance Fee LDMA P/C# above inf ation is correct. I agree to comply with all.County Investigation Fee ordi' ces d State law ing to building construction, t Total Fee LDMA Perm. # y r�� er uthorize re en atives this County to enter 6 u n e ove- a ti pr p or ns ion purposes, rte+ w• C'E e ::•� 1.3 I=i y...l s SEE REVERSE FOR EXPLANATORY LANGUAGE ' Signature of Applica/ or Agent Date `•t �� 4'" {; WORKERS' COMPENSATION DECLARATION i re bor� f{ascertif cate of Worke s'tCompensat ificate of on eInsurance, L nt to self ICA7110"IN FOR U I L®I IV G PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING �n ❑ Certified copy is hereby furnished. FOR APPLICAANT TO FILL IN ;ADDRESS / ❑ Certified copy is filed with the county building inspec- FADDRESS_ NG tion department. i ZIP LOCALITY Date Applicant F BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' F LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT A BLOCK LOT NO. MAP BOOK I PAGE I PARCEL hundred dollars ($100)or less.) TEL. OWNER A NO. USE ZONE MAP I certify that in the performance of the work for which this 51 '7SPE permit is issued, I shall not employ any peon in any manner' ''.ADDRESS 'SPECIAL a CONDITIONS so as to become subject to The Workers'Compensation Laws. J O CITY- ZIP U Date Applicant TEL. a L. G _�� DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate of E N G CONST. ZONE Exemption, you should become subject to•the Workers' Compensation provisions of the Labor Code, you.must forth- >°ADDR �fl4 n, with comply with such provisions or this permit shall be TEL. + STATISTICAL CLASSIFICATION CONDO. N deemed revoked. ? 114 0 NO. �1 ; ? I ; z LICENSED CONTRACTORS DECLARATION LIC. CLASS NOD` DWELL. UNITS _ I hereby affirm that I am licensed under provisions of Chapter 9 "ADDRESS NO. `r f.. SEWER MAP �°i (commencing with Section 7000)of Division 3 of the Business LIC. �j•',- and Professions Code,and my license is in full force and effect. CITY CLASS BK. PG VAlId/1TIdN SQ. FT. NO. OF NO.OF CHECK �` r—, License Number Lic. Class SIZE STORIES FAMILIES ONE TTIAL I• L 9—°_ 78 VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ �' 6.,11Z 1/ ADD El " Nat El am exempt under Sec. : �/°/ !' ALTER B.BP.C. for this reason i T $ REPAIR ❑ i, USE O 1-;(1(10,ILI- i Date: ❑ y;—{•- EXISTING BLDG. DEMOL i•�i+•{,i ta�.E.rSTI 1 APPLICANT TEL, (�r • Signature APP(PRINT) NO. FINAL x)° OWNER-BUILDER DECLARATION . DATE `�' f_ I hereby affirm that I am exempt from the Contractor's License `V Z " �-''f Law for the following reason (Section 7031.5, Business and ADDRESS FINAL /� 'CHANGE Professions Code): .PRESENT _ By ..1_• BUILDINGEl I, as owner of the property, or my employees with . ADDRESS wages as their sole compensation,will do the work and ; +_ -- .4,i the structure is not intended or offered for sale(Section, LOCALITY E i �:l i (;I j i •b{, '7044, Business and Professions Code.) MOVING TEL. �: _- I,as owner of the property,am exclusively contracting CONTRACTOR NO. +: A � with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code..) REQUIRED TOTAL SETBACK CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINEFROM EXIST. 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 p ® 0 0• 0 LDMA Ref.# P:C. Fee$ Permit Fee Lender's Address I certify that I have read this application and state that the' Issuance Fee a LDMA P/C# '— above information is correct.I agree to comply with all County Investigation Fee ordinances arid State laws relating to building construction, Total Fee LDMA Perm. # and hereby authorize representatives of this County to enter , upon bove-mentioned pr pe, for inspection ur ose . o 6 / (I® ~ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date