The URL can be used to link to this page

Home My Public Portal About6022 ROSEMEAD BLVD_Building__ WORKERS' COMPENSATION DECLARATION hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING P E RM I T insule, or a certificate of Workers' Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND AWY,, Policy No.//✓c)7� CompanylG��4Q;� 6&&L -L EJBUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESVOp'��- Certified copy is filed with the co my bui g i spec- BUILDING _r tion department. ADDRESS �/}��o� oZ C y L ,� �JL ` ,— Date ..� I Iipplicant CITY /(iii Ci/7' ZIP LOCALITY NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION F M WORT ERS SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the per it is for one TRACT• BLOCK LOT NO. MAP BOOK /Jr� PAGE PARCEL hundred dollars ($100)or less.) gg � TEL. USE ZONE MAP / OWNER L�l SO�- NO. I certify that in the performance of the work for which this - D SPECIAL a permit is issued, I shall not employ any person in any manner ADDRESS �2 �e�L�,�' —� CONDITIONS so as to become subject to the Workers'Compensation Laws. Or� CITY Z -/� ZIP VYPp U Date Applicant ARCHITECT OR TEL. O! FIRE NOTICE TO APPLICANT: If, after•making this Certificate of ENGINEER NO DISTRICT GROUP TYPNST. ZONE PROCESSED BY 0t- Exemption, you should become subject to the Workers' y - V Compensation provisions of the'Labor Code, you must forth- ADDRESS �QU - 3 11:6 a- with comply with such Provisions or this permit shall be TEL. �/� / STATISTICAL CLASS PT. CONDO. ' deemed revoked. CONTRACTOR � Oeurr D� �a�� NO.-7`� !y� Z_ LICENSED CONTRACTORS DECLARATION LIC. 2 y l �i CLASS NO. ELL. U TS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O r NO. O (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP CITY 2C.4.N,0�� CLASS 4C—l4 VALIDATION and Professions Code,and my license is in full force and effect. BK PG �/ 1l,, / f SQ. FT. NO. OF NO.OF CHECK License Number 7_ Z1 4 / Lic. Class `v`4 SIZE STORIES FAMILIES ONE Contractor 1 _ r R ' Date 1 L_1 "�Z•' DESCRIPTION OF WORK NEW VALUATION ADD ❑ $ 7,S � ❑I am exempt under Sec. ALTER ❑ ► B.BP.C. for thisrea n REPAIR ❑ $ ter ? �Z—T L USE �STOING BLDG. DEMO. ❑ Signature APPLICANTS PPLICANT TEL. FINAL / Q N -BUILDER D RATION (PRINT) NO• DATE I hereby affirm that I am exemp fro he Contractor's License Law for the following reason esti• 7031.5, Business and ADDRESS FINAL Professions Code): I PRESENT By ACCT.a El BUILDING I, as owner of the property, or my employees with ADDRESS ylyE 3 ,0 76.rj'■74 wages as their sole compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section , �.f�SL 1 ITEMS 7044, Business and Professions Code.) MOVING TEL. c, ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. J/7� TOTAL 2,�5 m 74 with licensed contractors to construct the project (Sec- ADDRESS �/ �Z (.HECK 265■74 tion 7044, Business and'Professions Code.) �� CONSTRUCTION LENDING AGENCY REQUIRED TOTAL SETBACK FROM EXIST. /f 1 1 SET BACK YARD HWY PROP. LINE WIDTH �•HPt�GE ■ 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 (�( I3I -I�t�{)1 1/14/93 Lender's Name 7628 1 AMIClo07 ,,`` � LDMA Ref.# Lender's Address P:C. Fee S. �U Permit Fee �7e• I certify that I have read this application and state that the Issuance Fee a 7 ' LDMA P/C# above information is corr t. I agree to comply with all County Investigation Fee ordinances d State I relat' g to building construction, Total Fee o LDMA perm. # and here authorize r resen Ives of this County to enter upo t abov - nti ed pr rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE nature of A . ant o Agent Date h ",sWORKERS' COMPENSATION DECLARATION , ns o ere affirm that I have certificate of consent to self iAPPLICATION FOR BUILDING P E RM I T insure, or a certificate of Workers' Compensation Insurance, or a cern e��opy� er�of(Sec. 3800!;.) C.) � COUNTY OF LOS ANGELES eW, • - BUILDING AND SAFETY Policy Noy Company 't- �/� AC ) El BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS GOZ2- SMTAO ❑ Certified copy is filed with th unty building i spec- BUILDING ABU DDRESS �G, - ✓ R�-- � b ,� D tion department. } p py/ (� Z � CITY \SMP L-S C ics \ zip C11 760 LOCALITY TSM RLa C— T Date CERTIFICATE OFPEXEMPTplicant ION OM WORKERS' SIZE OF LOT 16S.�NOW ON LOTNO.OF S � NEAREST CROSS ST. QQ-` A� COMPENSATION IN RANCE �1 //'� ASSESSOR � � (This section need not be comple d if the permit is for one TRACT Sq0 BLOCK LOT NO.�'.SIsis MAP BOOK PAGE e5V PARCEL o0C hundred dollars ($100)or less.) s` TEL. OWNER AL_ S-tAWTQO 1 NO. USE ZONE MAP �� 1a5 I certify that in the performance of the work for which this qq� ll e1 lj /� NO. c)- permit is issued, I shall not employ any person in any manner ADDRESS OT"D N• sT AM S /�' SPECIAL (/� CONDITIONS so as to become subject to the Workers'Compensation Laws. Qin O CITY AIS CAD i R ZIP t 1006 V Date Applicant ARCHITECT OR ./� pW ,.�� TEL. W NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER s`-!'� /�l�•s• itEc-1 NO. h�•Q��Jl r0 DISTRICT GROUP CONST. ZONE PROCESSED BY O Exemption, you should become subject to the Workers' /I_i L �(�-� Cs q 0�3� q CL Compensation provisions of the Labor Code, you must forth- ADDRESS Tt , l� �� '1�1 �..� a with comply with such provisions or this permit shall be 'aT TEL,/ "� STATISTICAL CLASSIFICATION APT,E. CONDO. N deemed revoked. CONTRACTOR e� t.- NOR] 705 J r Yj°y Z �-�r LIC .• CLASS NO.� DWELL. UNITS V LICENSED CONTRACTORS DECLARATION ii o /Ll L NO. y C I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1 v47J (commencing with Section 7000)of Division 3 of the Business SEWER MAP _ LIC. ,•-:r.- and Professions Co�dJteyJQ7nd]m ISc nse is in full force.a d effect. CITY CLAS r BK /1 PG. _VAL(Di4TION _ _- License Number W I 1 `IG-� Lic. Class �� SIOZEF STORIES License2 FAMILOIES J ONE K i, )/►'/�'I �/// /- _ VALUATION Contractor v '` "-~�O Date r17DESCRIPTION OF WORK NEW ADD ❑ V 1 civV ;�;rN. ❑I am exempt under Sec. WSW Vorr A9AR2't Mr_-1JT�' ► ALTER ��, BAP.C. for this reason $ REPAIR�❑ "'--_ -' _ -• Date: USE OF 1; EXISTING BLDG. DEMO' ❑ - ,,� .. Signature APPLICANT * TEL•ytf FINAL - + L OWNER-BUILDER DECLARATION (PRINT) AL �--TA6" rONO Al L•1 =4 �y d DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS -1d4•s pr �• LST �t� = L6 Law for the following reason (Section 7031.5, Business and -� FINAL Professions Code : T PRESENT By 1 i I BUILDING ,_,. _ I, as owner of the property, or my employees with ADDRESS �/� I`�'� 4'• = ' wages as their sole compensation,will do the work and v I I HL ` ` the structure is not intended or offered for sale Section LOCALITY '. •-�• 7044, Business and Professions Code.) MOVING TEL. , � {-�• ; i ,. l'n ❑ I,as owner of theproperty,am exclusively contracting CK CONTRACTOR NO. VV � ' ' C•yt+.r�t1 Y 9 Jn n.AN E with licensed contractors to construct the project (Sec- (�Yi tion 7044, Business and Professions Code.) ADDRESS REQUIRED TOTAL SETBACK FROM EXIST. {- r r p CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 0ol0o-�)�4_)1 r/ Lr: 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. G :i_ `'� 24 (Sec. 3097, Civ. C.). SIDE P.L. 4 Lender's Name �^ Lender's Address P.C. Fee$�� r C/•� Permit Fee Z LDMA Ref.# I certify that ve read this application and state that the Issuance Fee r LDMA P/C# '- above int anon is correct. I agree to comply with all County Investigation Fee /f Al3 ordina sand Stat laws tela}' g to building construction, Total Fee �r/"�i "/ LDMA Perm. # and re author' rept se fives of this County to enter 1\ p up t a ove- en i sptec�tia purpo s. o ! SEE REVERSE FOR EXPLANATORY LANGUAGE Sig tura of plicant or Agent Date