HomeMy Public PortalAbout5753 ROSEMEAD BLVD_Building__ WORKERS' COMPENSATION DECLARATION �� -���' ��G
hereby affirm that I have r certificate of consent to self ® L�( ,T I N F e R I P E RM I T
insure, or a certificate of Workers' Compensation Insurance, rr �/
or a certified copy, thereof(Sec. 3800(0, C.) •
/d_ Company`* 12V-WCOUNTY OF LOS ANGELES BUILDENG AND SAFETY
Policy No/ "`0
BUILDING
ElCertified copy is hereby furnished.,- FOR APPLICANT TO FILL IN ADDRESS 'Y!rd`Jl9LG.G yG r
Certified copy is filed with the county building inspec- BUILDING
tion department. f� g- �j,, ADDRESS ,,,
Date I"l Applicant '"zw �fA�. CITY a: /�'{/ LG CST` ZIP LOCALI �° C'
NO.OF BLDGS. NEAREST
CERTIFICATE OF EXEMPT N 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.
hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL
USE ZONE MAP
a TEL.
OWNER �. NO. NO.
I certify that in the performance of the work for which this NO.
^ SPECIAL >
permit is issued, I shall not employ any person.in any manner ADDRESS a.
so as to become subject to the Workers'Compensation laws.
v CONDITIONS O
CITY "ZIP U
Date Applicant• ARCHITECT OR TEL. DISTRICT I GROUP ITYPE FIRE OCESSED BY O
ad
NOTICE TO APPLICANT: if, after making this Certificate of ENGINEER NO. CONST. ZONE],,PR
,> 0
Exemption, you should become'subject to 'the Workers' ' �'� _� Lt tt� ✓ a
Compensation provisions of the Labor Code, you must forth- n ADDRESS
with comply with such provisions or this permit shall be �/�� �• /� TEL. �} STATISTICAL CLASSIFICATION ; APT. CONDO. N
deemed.revoked. CONTRACTOR�L7t/c�c�IE/k� W NO.71W�7�j6� �/-�C-' Z_
LICENSED CONTRAGTORS.DECLARATION' f� LIC. x/ CLASS NO. 92 DWELL. UNIW
I hereby affirm that I am licensed under provisions of Chapter Si ADDRESS/6b/,P I A-0,PVC R L;1J. NO.S 6 6 N'Z-2 SEWER MAP
(commencing with Section-7000)of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and effLL�. CITY �lO�i�N4-ISIJ ��cH CLASS �i• yrs BK. PG. VALIDATION
License Number Lic..Class L 6 SQ. FT. STONO.RIES
IE FA OF CHECK
ZZ SIZE STORIES ' FAMILIES ONE VALUATION
Contractor ,} �F DESCRIPTION OF WORK NEW ❑ $ ,�6�` p[
1 tF/��'=�fa/� Date t�,' (J
❑I am exempt under Sec. 5 GJ/T�I✓1�1 i li I-E r �S ADD ❑
.. ALTER ❑ t
B.BP.C. for this reason IMr LL /`LUQ ��/` r�r/ REPAIR ❑ $
D . USE OF
EXISTING BLDG. DEMOL ❑
Signature :a'APPLICANT TEL. FINAL
WNER-BUILDER DECLARATION (PRINT). NO. DATE j' " �
I hereby affirm that I am exempt from the•Contractor's'License
Law for the following reason (Section 7031.5, Business and ` ADDRESS FINAL L
Professions Code): PRESENT By
BUILDING :
❑ I, as owner of the property, or my employees with ADDRESS
wages as their'sble compensation,will do the work and =f"% <'
the structure is not intended or offered for sale(Section LOCALITY -
-J -r-..
:.:
7044, Business and Professions Code.) MOVING. � TEL.
❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. S•
with licensed contractors.to construct the project (Sec- it vi 4
tion 7044, Business and Professions Code.) ADDRESS
REQUIRED TOTAL SETBACK FROM EXIST.
-i Vjt% ice'a L.ti
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 2 - •EMP",
I hereby affirm that there is a•construction lending agency for FRONT s HEMP"':1
the performance of the work for which this permit is issued 'P.L. ,•, _,
(Sec. 3097, Civ. C.). SIDE TO AL 1-47. •-�8.
P.L. na} i•'; :? '
Lender's Name Q I-DMA Ref. N %' 6
P.C. Fee$ O• Permit Fee HANIK .00
Lender's Address
I certify that I have read this application and state that the ? Issuance Fee �� LDMA P/C N
above information is correct. I agree-to comply with all County s Investigatian Fee ;'I�) ;i;_ tf
/ �l_i3! s!t D, t:
ordinances and State'laws relating to building construction, Total Fee ,C� j LDMA Perm. 0
and hereby authorize representatives of this County to enter iT 1 1f
upon the above-mentioned property for inspection purposes. '
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date '