The URL can be used to link to this page

Home My Public Portal About5755 ROSEMEAD BLVD_Building__ i WORKERS'COMPENSATION DECLARATION 1 1-hereby affirm that I have a certificate of consent to self AP . WIL®INPERAIT insure, or a certificate of Workers' Compensation Insurance, ®i " or a certified copy thereof(Sec. 3800,Company � 7ir— Lob. C.) J COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NoW- ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING �5� 5 ❑ Certified copy is'filed with the county building inspec- I BUILDING DRESS 7Qgs'�11WF717 tion department. Date� `3 �lApplicant !mss ZIP r LOCALITY S< F NO. Or BLDGS. NEAREST / CERTIFICATE OF EXEMPTION:FROM WORKERS' - SIZE OF LOT 9G 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 certifythat in' the'performance of the work for which this NO. permit is issued, I shall not employ an person in an manner ADDRESS SPECIAL o- p P Y Y P Y ,; CONDITIONS � so as to become subject to the Workers'Compensation Laws. t V � CITY ZIP Date 's !3 f{picant AR ITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO 'APPLICANT: If, after making this Certificate of ENGINEER NO. ' CONST. ZONE Exemption, you should become subject to the Workers' u ,aro r/' 3 Compensation provisions of the Labor Code, you must forth- ADDRESS CL N with comply with such provisions.or this permit shall be %CONTRACTOR / LGG�C /NO STATISTICAL CLASSIFICATION APT.. CONDO. Z deemed revoked. UNITS— LICENSED-CONTRACTORS DECLARATION f—pGvr v� �CC N� j��Ci� ,' CLASS NO. a DWELL. I J I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS SEWER MAP (commencing with Section 7000)of Division 3 of the-Business L� LIC. ��its and Professions Code,and my license is in full force and effect. CIN CLASS BK. PG. VALIDATION �/� t� n SQ. FT. NO.OF NO.OF CHECK License Number ,`��T Li.. Class ✓ SIZE STORIES FAMILIES ONE .. VALUATION Contractor ' Date DESCRIPTION OF WORK NEW //V D�1/J OGs�L ADD ❑ ❑I am exempt under'Sec. CriS'�'N.vc� ALTER ❑ ,., B.&P.C. for this reason •• �IG�C REPAIR ❑ $ -- ' ""�'_' • -- ' Date: USE OF ��lL ❑ EXISTING BLDG. DEMOL Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. Thereby affirm that I am exempt from the Contractor's License DATE r Law for the following reason (Section 7031`5, Business and ADDRESS FINAL Professions Code): PRESENT By ` BUILDING❑ I% , as owner of the property, or my employees withADDRESS wages-as their sole compensation,-wi I I do the work and ___ .: r•: the structure is not intended or offered for sale(Section LOCALITY00 7044, Business and Professions Code.) M01/ING TEL. y • ElI,as owner of the,property,am CONTRACTOR NO,exclusively contracting _ '•--• - ,,,;.;•.•:- with licensed contractors to construct the project (Sec- ADDRESSt j zs tion 7044, Business and Professions Code.) , y;11 '=` REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK 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 P.L. L - ^ a•sem• (Sec.•3097, Civ: C.). SIDE T-1'A - -' - s '^123 P.L.` �EL: Lender's Name CHECK iL.`s O LDMA Ref. q ` P.C. Fee$ Permit Fee Q CHANGE , Lender's Addrt•is ' I certify'that I hwe read this application and state that the Issuance Fee o? F> P/C# above informatio�n)is correct. I agree to comply with all County Investigation Fee yf ,{ E13 j;1l i__'I�(Ll f 111 ordinances and :tate laws relating to building construction, Total Fee t� a4 ./ LDMA Perm. # and hereby autholize representatives of this County to enter 3 • upo a ab nti ed ropert f�r i ection purposes. t .- - o• Am D36 V ':j;./ SEE REVERSE FOR EXPLE.NATORY LANGUAGE Signature of Applicant or Agent : Date .. � • :, WORKERS' COMPENSATION DECLARATION ffJ4y__1 � I hereby affirm fI have certificate of consent to self P L I CAT I O R U I L D I N G P E RM I T insure, or a certificate of Workers' Compensation Insurance, ' or a certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING •ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS47 Date Applicant CITY ft L� ZIP LOCALITY NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' i'SIZE OF LOT JJ dQ 7 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 `514A O NO.t�IG/V1't"'_,A USE ZONE MAP I certify that in the performance of the work for which this ; permit is issued, I shall not employ any person in any manner 'ADDRESS / g,__4.4,VV j7_ s-r tel, a3,;l s SPECIAL ck- so as to become subject to the Workers'Compensation Laws. CONDITIONS O CITY V,ALZ- ZIP 4 2t74/. Date Applicant !'. ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE P CESSED BY 0 NOTICE TO APPLICANT: If, after making this Certificate of . ENGINEER NO. CONST. ZO E Exemption, you should become subject to the Workers' ��,�p V tU Compensation provisions of the Labor Code, you must forth- ADDRESS ,GCl a with comply with such provisions or this permit shall be TEL. + STATISTICAL CLASSIFICATION 7 APT. CONDO. Z deemed revoked. CONTRACTOR NO. _ _ LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. -2a DWELL. UNITS _ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business LIC• SEWER MAP -�, and Professions Code,and my license is in full force and effect. , CITY CLASS BK `"`'`'VALIDATION SQ. FT. NO. OF NO.OF CHECK License Number Lic. Class , SIZE I STORIES FAMILIES ONE VALUATION €;��,5_ 355 - 41 �-,_E _ � Contractor Date DESCRIPTION OF WORK NEW $ �� - _ `� t • �yv:. ❑I am exempt under Sec. rT. ADD ❑ • 6F, "Cir t,y j t: ALTER ❑ ® i•jlA SE B.&P.C. for this reason i2gsnrlvwAa-A.-, EPAIR ❑ $ Date: USE OF I DEMOL ❑ '._.':� +EXISTING BLDG. I e APPLICANT -.03"!i - _ (PRINT) NO FINAL OWNER-BUILDER DECLARATION DATE + • ��.Lti• I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL �`- =..5 1- I-� Pro}essions Code): PRESENT By m 7c I`O I iAL �LY7�II I, as owner of the property, or m employees with BUILDING CASH ,,c P P Y+ YADDRESS }:;1�,1.0 wages as their sole compensation,will do the work and _., the structure is not intended or offered for sale(Section LOCALITY C A?ytI�_ ; 7044, Business and Professions Code.) MOVING TEL. 100 ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS !I 1_f1 iif�l_i, f.4 tion 7044, Business and Professions Code.) REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. Y`i [+� Cyt �c CONSTRUCTION LENDING AGENCY SET BACK 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 P.L. (Sec. 3097, Civ. C.). SIDE P.L. 8 Lender's Name r� LDMA Ref.# P.C. Fee$ c7 7 Permit Fee Lender's Address �� r 0 I certify that I have read this application and state that the Issuance Fee J LDMA P/C# above information is correct.I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee t. ,3 LDMA Perm. # and hereby authorize representatives of this County to enterejLg i. upon the above-mentioned'property for i spection purposes. o �J/yj h SEE REVERSE FOR EXPLANATORY LANGUAGE Signature W Appli or Agent Date