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Home My Public Portal About6030 ROSEMEAD BLVD_Building__ TJ - I WORKERS'COMPCNSATION DECLARATION I_hereby affirm that I have rkers' Come of tion Int to self APPLICATION FOR BUILDING PERMIT in?;ure, or a certificate of Workers' Compensation insurance, or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAF Policy No/455-?24' Compan ......L11,1. BUILDING Certified copy is hereby furnished. 'FOR APPLICANT TO FILL IN ADDRESS 'Se elL-A-0 {ALJ r Certified copy is filed with the county b in 'nspec- BUILDING / d � ,� _�? e `L tion department. ADDRESS CO/� Dote�4�APplicant CITY-4Nf L' e Gt'f" ZIP LOCALITY —' NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION OM WOK S' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR hThis section need not be completed if the per• it is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL undred dollars ($100)or less.) TEL. OWNER �i NO. USE ZONE NOP rj A/ I certify that in the performance of the work for which this SPECIAL permit is issued, I shall not employ any person to any manner ADDRESS //, .� -� CONDITIONS 0 so as to become subject to the Workers'Compensation Laws. L) CIN ''D" J ZIP ad Date Applicant ARCHITECT OR TEL. ry DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.��! CONST, ZONE C.J Exemption, you should become subject to the,. Workers' Compensation provisions of the Labor Code, you must forth- ADDRESSa - Z with comply with such provisions or this permit shall be IJ?� rs't',A4 TEL r/ STATISTICAL CLASSIF� APT. CONDO. P Y P P CONTRACTOR i� t DE �"��+ NO. � !�LJ� L r✓y deemed revoked. LICENSED CONTRACTORS DECLARATION c� LIC. )� CLASS NO. DWELL. ITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ti r r 4�Q� NO L T f� SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC'L(,4,a i A CLASS �„�-�� C and Professions Code,and my license is in full force and effect. CITY BK. PG. VALIDATION / t / SQ. /41 tom.OF NO.OF CHECK ----- License Number b ` q LI.. Class ` SIZE n STORIES ,r- FAMILIES ONE VALUATION E p I Contractor §�. * Date ' �5 Z� DESCRIPTION OF WORK NEW tG F. S�!�j t.l 1�4 caL s ADD ❑ tf ► ❑I am exempt under Sec. ALTER ❑ B.&P.C_ for this r n REPAIR ❑ $ USE OF DEMOL ❑ EXISTING BLDG. Signature APPLICANT NO. FINAL bVFNfR-AUILDER ATION DATE 1 hereby affirm that I am exempt ram Contractor's License ADDRESS FINAL Law for the following reason ( ctio 7031.5, Business and Professions Code): PRESENT By BUILDING❑ i AUCTna I, as owner of the property, or my employees with ADDRESS 14`� wages as their sole compensation,will do the work and 5a1�� t =�!-f F the structure is not intended or offered for sale(Section LOCALITY po ��, %/ 7044, Business and Professions Code.) MOVING TEL' i ITEMS ❑ �lJ•� _I, as owner of the property,am exclusively contracting CONTRACTOR NO. v�- '� » -74 with licensed contractors to construct the project(Sec- ADDRESS t j � � -� tion 7044, Business and Professions Code.) . , /��f CHECK 904 R TAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pR P. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT CHANGE °130 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. 13000-0001 1/14/93. Lender's Name g l LDMA Ref.# +•t H ^� 3 P.C. Fee$ Permit Fee P �' / L� l tj%'j16 Lender's Address I certify that I have read this application and state that the issuance Fee :R-Al 76 LDMA P/C# above information is correct.1 agree to comply with ail County Investigation Fee �y f � ordinances and St laws relating to building construction, Total Fee C b . LDMA Perm.# ( and her y author z re resentatives of this County to enter t li n e a ve- io d property for inspection purposes. , /L_1 1�?.- I SEE REVERSE FOR EXPLANATORY LANGUAGE __T§I'gnoturedricont or Agent Date e :,WORKERS' COMPENSATION DECLARATION re,y,affirm.that I have certificate of consent to self insu APPLICATION FOR 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, COUNTY 1 COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N . Company 7 � -Rix) %dk BUILDING ❑ Certi i s hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with tpen'y building iF BUILDING ,� / �v e a ! tion dep tment. ADDR Q GI/� �1 � Date _ ApCIN e C! ZIP f! �eL LOCALITY v L-fes CERTIFICATE OF EXEMPTIOWORKERS' / NO.OF BL OT NEAREST ,. COMPENSATION ICE SIZE OF LOT �SQ �� NOW ON LOT CROSS ST.ASSESSOR(Thissection need not be complete permit is for one TRACT BLOCK LOT NO. �� MAP BOOKd PAGE �� PARCEL Z7 hundred dollars ($100)or less.) TEL USE ZONE MAP OWNER L NO. MA ^ �S I certify that in the performance of the work for which this 9D �r 1� �! e�T+ SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS 7 ib CONDITIONS so as to become subject to the Workers'Compensation Laws. y f CITYn-GA-D/ ZIP U Date Applicant ARCHITECT OR TEL. ?r/ ENGINEER S C 3 DISTRICT �GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of �iC NO. rJ CONST. ZONE CJ Exemption, you should become subject to the Workers' u G Dd 'J w Compensation provisions of the Labor Code, you must forth- ADDRESS 7 /j S / V — t:• N with comply with such provisions or this permit shall beTEL. L C STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR •� � � NO. 7/OJ �• �,� — LICENSED CONTRACTORS DECLARATION r /A� /� LIC. --�-t-� CLASS N0.�DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS f� tlG NO. ` t f LIC. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and Professions Codi,and m li is in full force effect. CITY C�1 /� CLASS BK//a PG ,�Gl VALIDATION- _e SQ. FT.f NO. OF NO. OF CHECK 1 L I r'�_ License Number Lic. Class SIZE 6 STORIES FAMILIES 'J ONE :. �/� /J L1-7-7-7 _C��7 VALUATION t:i.is,;j Contractor4 1.1J&1 "� Date _1-7 . ` CJ DESCRIPTION OF WORK NEW $ f J a�o ❑I am exempt under Sec. S V/ff T 1 ADD ❑ �J ► t•I-`I'� uL v ALTER ❑ BAP.C. for this r son REPAIR ❑ ; I_j_( =�_I_I_I�t j, Date.: USE OF EXISTING BLDG. DEMO L ❑ �`3,�4 ` :`i Signature APPLICANT �+ A ��L• 7 f FINAL / Q OW R&ILDER DECLARATIO (PRINT) L / ryNo. DATE 1 hereby affirm that am exempt from the Co tractor's License /y t11 n A f l r Law for the follow ng reason (Section 7031.5, Business and ADDRESS V ,V/ �e FINAL i Professions Code): PRESENT By ACCT. .-. BUILDING ❑ I, as own r of the property, or m em to ees with C' °AT P P Y: Y P Y ADDRESS t 5.3-3 7 wages as their sole compensation,will do the work and y t q•1�,:�,�� the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. , p I 1 T)EMS, ❑ 1,as owner of the property,am exclusively contracting CONTRACTOR NO. C �I �� ', with licensed contractors to construct the project (Sec- ,^ n 1/ OTAL 0223"`4 ADDRESS 11� tion 7044, Business and Professions Code. CHECK✓!7l' �rt1�t4=` REQUIRED TOTAL SETBACK FROM EXIST. I,II CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH t� I,� E I hereby affirm that there is a construction lending agency for FRONT CHANGE =011 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name /J 13CI'13�+J 9f 17/92 Lender's Address P.C. Fee$ �� /� Permit Fee ' LDMA Ref. # Lv 1 Aril 9.02� �q r7`.� I certify at I have read this application and state that the Issuance Fee a /` / LDMA P/C# , above in rmation is correct. I agree to comply with all County Investigation Fee 1/ Q d Ord Inon and State laws eating to building construction, Total Fee 7��0'C LDMA Perm. # and her y authorize repr tatives of this County to enter upon th bove-mentione r perty for insTHYT:z— SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of Applicant or Agent Date