HomeMy Public PortalAbout6148 ROSEMEAD BLVD_Building__ WORKERS' COMPENSATION DECLARATION
bbrelryaffirm that I have certificate oconsent to self
+insure, or g certificate of Workers' opensation Insurance, APPLICATION FOR BUILDING PERMIT
or,a certifies)copy thereof(Sec. 3800,/Lob. C.) �-���! COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No., d Oc Company 5D TE ��_J-)
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING _ L�
ADDRESS
❑ Certified copy is filed with the county building inspec- ADDRESS Gj �5� �/�-[� �f D.tion department.
Date d Applicant- �+`7 /� ��L� CITY /(,� L rrrY ZIP LOCALITY
J iNO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT _ �J X/ OW ON LOT CROSS ST.
COMPENSATION INSURANCE A ASSESSOR
(This section need not be completed if the permit is for one TRACT O BLOCK LOT NO. [ Mqp BOOK PAGE PARCEL
hundred dollars ($100)or less.) �;�
OWNER ` (/�✓��� . NO USE ZONE MAP
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any manner ADDRESS JA/. .V&y SPECIAL a
so as to become subject to the Workers'Compensation Laws. CONDITIONS O
CITY tTIN9.1it zip U
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE ROCESS D BY O
Ix
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER L` f [J O. O CONS: E F
Exemption, you should become subject to the Workers' / �-j e��e
LU
Compensation provisions of the Labor Code, you must forth- ADDRESS =�fr/ >�I � / /•4� Ig.
�J CL
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION AP . CONDO. Z
deemed revoked. CONTRACTOR NO. _
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class �• SIZE �( STORIES C FAMILIES ONE
�k'D 17,14V Date ^a V DESCRIPTION OF WORK NEW VALUATION
/
Contractor
Elam exempt under Sec. ADD ❑ s v
� _ ALTER ❑
B.&P.C. for this reason S6 REPAIR ❑ $
Date: USE OF
/}� r EXISTING BLDG. DEMOL ❑
Signature 1 ��1t/�• L �a APPLICANT TEL,
OWNER-BUILDER DECLARATION (PRINT) NO. FINAL & )3_ 91
1 hereby affirm that I am exempt from the Contractor's License DATE i
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT By / g
AC
CCT
❑ I, as owner of the property, or my employees with ADDRESS .,r CY 7,
wages as their sole compensation,will do the work ander) 1834.75the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL. 1 !TEAS
❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. TOTAL 1°�'4o -
JJ
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) �t �-+! 75
REQUIRED TOTAL SETBACK FROM EXIST. CHECK 1834.1'�
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROp, LINE WIDTH r-
Ihereby affirm that there is a construction lending agency for FRONT ` ', CHANGE .Lk
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L. 1. 00113-130131 4/ 5/913
Lender's Name �n
P.C. Fee$ Permit Fee (�� • �� LDMA Ref. # 9929 1 AM 9 50
Lender's Address 7 7 I 1
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 Investigation Fee .n�c�
V ordinances and State laws relating to building construction, Total Fee 3 . Z5 LDMA Perm. #
( and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
I41.,L), it,/,
• —�Gp ) SEE REVERSE FOR EXPLANATORY LANGUAGE
t-ure of or Agent Date