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Home My Public Portal About5799 ROSEMEAD BLVD_Building__ WORKERS' COMPENSATION DECLARATION ° APPLICATION FOR. BUILDING PERMIT . `I-hereby affirm that I have a certificate of consent to self , insure, or a certificate of Workers' Compensation Insurance, or a certified cop' there of'(Sec.,3800, Lab:.C.) °. -COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N.. 2-Company� G� '7 '- �//V�C] ❑ BUILDING Certified copy is hereby.furnished. ' '+ �. ' FOR APPLICANT TO FILL IN ADDRESS ® ' Certified copy-is filed with the county building inspec- BUILDING' tion department. n, ADDRESS D.ate'� -Applicant a-1"s• CITY' ZIP ' LOCALITY d N OF BLDGS. NEAREST -CERTIFIC TE 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 t OWNER NO USE ZONE MAP I certify that in the performance of the'work fat which this NO. permit is issued, I shall.not employ any person in any manner ADDRESS SPECIAL a CONDITIONS so-as to become subject•to the Workers'Compensation Laws. O ` • CITY•. ZIP Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY a! NOTICE TO APPLICANT: If, after making this-Certificate of ENGINEER NO. CONST. ZONE .0 Exemption, you should become subject to the. Workers' w Compensation provisions of the Labor Code,-you must forth- ADDRESS ra �S I' 5 o_ ,with comply -with such proyisions:or this permit shall be TEL. STATISTICAL CLASSIFICATION. APT. CONDO. Z Actemed`revoked. CONTRACTOR S NO. 4G LICENSED CONTRACTORS.DECLARATION LIC. CLASS NO. �a DWELL.UN I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO ZO SEWER MAP (commencing with Section 7000)of Division 3 of the:BusinessLIC. and Professions Code,and my license is in full force and effect. CITY p '/�Q/f CLASS BK PGVALIDATION SQ:FT. . NO.OF.' NO.OF CHECK License Number ' 2.O LIC. Class, SIZE I STORIES FAMILIES ONE � VALUATION Contractor rf6 to — DESCRIPTION OF WORK NEW $ ElI-am exempt under Sec. ADD: El , ALTER ❑ , c B.&P.C. for ihis'teason' $ USE,OE REPAIR ❑ Date:' EXISTING BLDG. DEMOL ❑ APPLICANT — - TEL. Signature (PRINT) as NO. .. FINAL OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor's License / 7 Law for'the fdllowing reason (Section 7031.5, Busiriess and ADDRESS C FINAL Professions Code): PRESENT Byt 'i a BUILDING Vit-*•I`°`+ ❑ J I' as owner.of the property, or my employees with ADDRESS vu I r wages as their sole compensation,-will do the work and k the structure 1s not intended or offered for sale(Section ' LOCALITY 7044, Business and Professions:Code.) MOVING TEL. s CONTRACTOR NO.• ❑ I,as owner of the property,am.exclusively-contracting n% with licensed contractors-to construct the project-(Sec- ADDRESS tion 7044, Business and Ptofessions Code.) REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE 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. ri) � - : (Sec. 333 097, Civ..C.).` SIDE - Lender's Name' LDMA Ref. # ii P.C. Fee$ U• Permit Fee • �O '-HfNEr -Lenders-Address 7 14 1•certify that I have r ad thi application and state that the Issuance Fee c;17 /� LDMA P/C# , - above information is c ect gree to comply with-all County Investigation.Fee // i�':�;I_i`rI; n s C:- 3 ordinances and Sfa I ing to building construction, Total'Fee LDMA Perm.# and hereby outh ze t ti es of this County to enter = ?7 I AN 9!"z upon the abov entp r r inspection purpos s. o ?ter Y ^' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of plicant or Agent Date •WORKERS'-COMPENSATION DECLARATION d� L% I hJr$by affirm that I have a certificate of consent to self insCompensation insure, or a certificate of Workers' Insurance, APPLICATION F®R 3 U 1 ®1 N G P E RM I T or a certified copy thereof(Sec. 3800, La . C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Po l' y No./�/o��Compony BUILDING Certified copy is hereby furnished. ��`� FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ///J f ADDRESS Date��APPlicaaf4� __'_ /7.Q� CITY ZIP LOCALITY -zTi O. OF BLDGS. NEAREST j_ /1 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' USE ZONE MAP OWNER. .NO. MA I certify that in the performance of the work for which this �_ 2 SPECIAL permit is issued, I shall not employ any person in any manner ADDRESSi Q CONDITIONS O so as to become subject to the Workers'Compensation Laws. U CITY ZIP Date Applicant ; ARCH ECT OR TEL. u OC NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER y� 3 DISTRICT GROUP CONST. ZONE P CESSED BY O Exemption, you should become subject:to•the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESSI� /•Y�/�.��HJ'1/ ,�Q(P V ' a with comply with such provisions or this permit shall be r TELL STATISTICAL CLASSIFICATION APT. CONDO. N -Y d l G✓GI+N z . ' deemed revoked. CONTRALTO •- , LICENSED.CONTRACTORS,DECLARATION' IC. CLASS NO.�DWELL. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 3_ 2 1 L.C. SEWER MAP (commencing with Section 7000)of Division 3 of the Business .d. �_ and Professions Code,and my license is in full force effect. Cl CLASS BK PG. V.AkIDATION License Number. Lic. Class EFT SIO OF TORIES FAMILOIES ONE K /,,,(/ VALUATION Contractor4di lad0 �� Date Z_ �•DESCRIPTION OF WORK NEw ❑ $ �D __, _ ADD ❑ �, S ❑1 am exempt under Sec. r - P ALTER B.&P.C. for this reason = _ ) USE OF Date: Ls REPAIR ❑ $ - i'1 .,;l� ''`•�.t�') ,; '` ,:•. s� EXISTING BLDG. t�� DEMOL ❑ °,.. r•L a; �t-p- -i APPLICANT'. TEL. �s, `IL-,.-1+, Ins Signature y FINAL OWNER-BUILDER DECLARATION (PRINT) NO• DATEell, �f'Zr?' .t „ •sj= I hereby affirm that.l am exempt from the Contractor's License �j l i.'_;'?I iY {}•,=d Law for the following reason (Section 7031.5,, Business anADDRESS ®d y� FINAL :•!-i�:�•+ -- - __ ,%..� Professions Code)- BYPRESENT 1"; �'' - 1 [ � . BUILDING ^''-+?="�'� � �"•_-I�• ❑ I, as owner of-the property, or my employees with ADDRESS V wages as their sole compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section I7044, 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.) CONSTRUCTION LENDING AGENCY SETT BACK. YARD HWY TOTAPROPALINEFROM 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. Lend er's'Narrie ' 8 +1 A 7� �[a o LDMA Ref. # • P:C.,Fee$ • Permit Fee V V a Lender's Address q 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 K;Investigation Fee •• Jr� ordinances and State laws relating to building construction, " Total Fee iv 16 LDMA Per # and hereby authorize representatives of this County to enter - upon the bove-. tione property for i spectiioon purposes.. SEE REVERSEFOR EXPLANATORY LANGUAGE Signature of Apppl'icon-t or Agent Date