HomeMy Public PortalAbout6132 ROSEMEAD BLVD_Building__ WORKERS' COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified co y t1hWeJec. 3800, LabrC.)
COUNTY OF LOS ANGELES BUILDING AN_SAFETY
Policy No. mpanyB LD NG
f r
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS �•-''! �`��'
,• Certified copy is filed with the couJ�t buildi nspec- BUILDING
tion eparti/r ePt j j -ADDRESS ..�fC 13" ( t� �{/� F-4—,V P
Date I I Applicant l lj CITY I�.R� �_ i ZIP LOCALITY
CERTIFICATE OF EXEMPTION FftO WORKERS' SIZE OF LOT �!{ NOW ON LOTS -^ CROSSSST.
NEAR
COMPENSATION INSURANCE
(This section need not be completed if the permit is for oner./_ f!q ASSESSOR }:
hundred dollars ($100)or less.) TRACT '( BLOCK LOT NO. t MAP BOOK PAGE PARCEL D_
1 certify that in the performance of the work for which this OWNER _, P i �I NO. ( USE Z E OP O
l / r-
lLl
permit is issued, I shall not employ any person in any manner SPECIAL
ADDRESS I#,� (" �_�,(�'+ � -''Z '-I
so as to become subject to the Workers'Compensation Laws. CONDITIONS r--
"�f tom. ZIP
CITY � Y >
Date Applicant
ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER l t ( �1 . /� ( NO. I CONST. ZONE
Exemption, you should become subject to the Workers' �,
Compensation provisions of the Labor Code, you must forth- ADDRESS ~- " f� Vt
with comply with such provisions or this permit shall be
deemed revoked. CONTR R TEL. STATISTICAL CLASSIFICATION / APT [CONDO
NO.; / LLI
LICENSED CONTRACTORS DECLARATIONLIC. / y�( CLASS NO. DWELL. UNITS
1 hereby affirm that I am licensed under provisions of Chapter 9 ADD f u �'j NO. I�
(commencing with Section 7000)of Division 3 of the Business and LIC, SEWER MAP
L.
' _ s�
Professions Code, my, se is in full force and eff t. CITY CLAS BK (, �n / VALIDATION
Jv� _ SQ. FT. Nd. OF NO. OF CHECK
License Num er Lic.Class SIZE STORIES FAMILIES j ONE
DESCRIPTION OF WORK NEW VALUATION
Contractor Date ADD $ ,
I am exe t under Sec. L ' f
ALTER ❑ 1
B.BP.C. for this reason REPAIR :
Date: USE OF DEMOL 0 ° • f • k
EXISTING BLDG. „ •
Signature APPLICANT TEL. FINAL
g PRINT NO.
OWNER-BUILDER DECLARATION 1 DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Q
Professions Code): PRE EN BY
BUILDING
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.
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).
REQUIRED EX
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROBACNEF 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.
Lender's Name
LDMA Ref. M
Lender's Address P,C. Fee$ Permit Fee '
I certify that I have read this application and state that the
y pp Issuance Fee LDMA P/C M
above information is correct. I agree to comply with all County Investigation Fee ,.r�^y
ordinon es and State laws relating to building construction, t a� !° LAMA perm. M
and,h e4y outhori representatives of this Count to enter Total Fee
upon t e bove ioned property for inspection u o
��t L t
SEE REVERSE FOR EXPLANATORY LANGUAGE
n -Signature of Applicant or Agent Date