HomeMy Public PortalAbout6029 ROSEMEAD BLVD_Building__ WORKERS'COMPENSATION DECLARATIONoFfirm that I have a certificate of •'
to self
o, a`certif cote of Wo ke s' Compensat on ent Insurance, A P ���I®N ®R U I L D I N C PERMIT
or a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF,LOS ANGELES BUILDING AND SAFETY
Policy No. Company
PY v FOR APPLICANT TO FILL IN BUILDING
Certified co is hereby furnished. ADDRESS 0 •
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
Date Applicant_ CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLD NEAREST
COMPENSATION INSURANCE SIZE OF LOT t. NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL {
TEL. USE ON MAP
I certify that in the performance of the work for which this OWNER NO. NO.
rn is issued, I shall not employ any person in any manner SPECIAL
so as
to become subject to the Workers'Compen ation Laws. ADDRESS CONDITIONS
®i CITY P
Date � Applicant - ARCHITE OR T
NOTICE TO APPLICANT: If, after making this Certiflca f ENGINEER NO. DISTRICT UP TYPE Flgggggg������ CESSED BY
Exemption, you should became subject to the Workers' ®� CONS KA5 . E
Compensation provisions of the Labor Code, you must forth- ADDRESS
IG <
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASVqCAJrION APT. CONDO.
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. QU DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �201NO. SEWEJ P
(commencing with Section 7000)of Division 3 of the Business and LIC,
Professions Code,and my license is in full force and effect. CITY A Mft CLASS BK. VALIDATION }
SQ. FT NO.OF NO.OF CHECKD:
License Number Lic.Class SIZE STORIES FAMILIES ONE 0
VALUATION U
DESCRIPTI N OF WORK NEW
Contractor Date ADD ❑ $ �° Q
I am exempt under Sec. ,
ALTER Ld
B.BP.C. for this reason REPAIR ❑ $ �-
USE OF N
Date: EXISTING BLDG. DEMOL ❑ Z
Signature APPLICANT TEL.ff FINAL 7® —
OWNER-BUILDER DECLARATION PRINT NO. DATE P�Q
I hereby affirm that I am exempt from the Contractor's License L-
Law for the following reason (Section 7031.5, Business and ADDRESS FIN yt,";tz T•s
n
fessions Code): PRESENTBY
BUILDING _ll7 .i(_•85
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL. TOTAL a
❑ CONTRACTOR NO.
I, as owner of the property, am exclusively contracting t:'-iEC •;7 d-
?C
"272
with with licensed contractors to construct the project (Sec- ADDRESS •
tion 7044, Business and Professions Code). r'`" t1 fl�l
REQUIRED TOTAL SETBACK CHAIN:3 .00
CONSTRUCTION LENDING AGENCY SET BACK RD 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 P.L. av 0 l l)jll�_l,( 1133
(Sec. 3097, Civ. C.). SIDE
P.L. rall
!t- `
Lender's Name '_` ` I
o `P.C. Fee$ Permit Fee 2 t•,'UQ
1.CDMA Refl q t
Lender's Address ; " tF•
I certify that I have read this application and state that the Issuance Fee �• .LDMA
above information is correct. I agree to comply with all County Investigation Fee F ` 90
•-�
°o ordinances and State laws relating to building construction, Total Fee • .70dLbN1A�Perm.p -
n and hereby authorize representatives of this County to enter
$ upon the above-mentioned pr t r for inspection purposes. , "� ,•__
m r -+ SEE REVERSE FOR EXPLANATORY LANGUAGE' t I •� t��
Signature of Applicant or gen -Date"" rlpl •� +_:� h f y i�I