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Home My Public Portal About6152 ROSEMEAD BLVD_Building__ WORKERS' COMPEIISATION DECLARATION affirm that I have certificate of consent to self APPLICATION F®R 3 U I L D I G PERMIT i insure, a or certificate of Workers' Compensation Insurance, or-a certified copy ,ereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY 1dlJ.S / Com S �utiD Policy No pony � � � nn BU LDING ElCertified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS a C � C�LV O ❑ Certified copy is filed with the county building inspec- BUILDING - rr1�1 tion department. / �J ' ADDRESS ,'� 0 e Date Applicant `At '�� C= N CITY L GIT ZIP LOCALITY NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT IPJ��U� NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACE BLOCK LOT NO. 7 O MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL. OWNER -AAJ NO. USE ZONE MAP I certify that in the performance of the work for which this hh!� NO. P employ Y P Y k72 A), & n V �Y SPECIAL a- permit is issued, I shall not em to an person in an manner ADDRESS CONDITIONS so as to become subject to the Workers'Compensation Laws. } , /-y� O CITY /v/Gti T - ZIP J�) )" U Datoe e Applicant ARCHITECT O TEL. O� DISTRICT G OUP TYPE FIRE PROC SED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER /' NO ,?� -D r7 CONST ZONE F Exemption, you should become subject to the Workers' _ • Compensation provisions of the Labor Code, you must forth- ADDRESS j o s ✓ ._� o_ with comply with such provisions or this permit shall be TEL• STATISTICAL CLASSIFICATION A CONDO. u7 deemed revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION LYON, SQ. FT. - NO. OF .r7 NO. OF CHECK License Number L/ O ,d > Lic. Class Is SIZE 3/J � STORIES DZ NO ONE ,, �r� VALUATION Contractor le-)060 /�$," (' Date �� DESCRIPTION OF WORK NEW $ a� 00� V ❑1 am exempt under Sec, /ii. S d VLdk ADD ❑ poll_ ALTER El B.BP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature [ `� �•' APPLICANT TEL, g OWNER-BUILDER DECLARATION (PRINT) NO, FINAL DATE I hereby,offirm that I am exempt from the Contractor's License C� Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): I PRESENT By �v {;C.Y o A ❑ I, as owner of theproperty, or m employees with BUILDING _ YADDRESS -,-* � '1C wages as their sole compensation,will do the work and ® 3307 18-'4°r-� the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. 1 ITEMS C I,as owner of the property,am exclusively contracting CONTRACTOR NO. Tj�TAL 11834.753�,?,,t with licensed contractors to construct the project (Sec- i7: tion 7044, Business and Professions Code.) ADDRESS CHECK1834.1c CONSTRUCTION LENDING AGENCY REQUIRED YARD HwY TOTAL SETBACK LINEFROM wIDTFI CHANGE ..I' I hereby affirm that there is a construction lending agency for FRONT e the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE Lender's Name. P.L. MOOR all 0000110-010101 4 5/90 $ LDMA Ref. # 99218 1 AM 9:513 Lender's Address P.C. Fee$ Permit Fee � •� 110111. I certify that I have read this application and state that the Issuance Fee J r LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee ,Q ordinances and State laws relating to building construction, Total Fee U LDMA Perm. # and hereby authorize representatives of this County to enter MEN upon the above-mentioned property for inspection purposes. rl u r L10% 'IGo 44 y&40 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent D s.v,�t\r,w \.Veto 4t\MI•'t,t\ft\Vi.4.�Y'fMt{Vi\ ' 1 I horeby off irm that I have a certificate of consent to serf APPLICATION FO B U I L D I tai f;► PERMIT w, insure, or a certificate of Workers'Compensation insurance, or,a certified copy thereof(Sec. 380Dy. , Lab. C.) 1 COUNTY OF LOS ANGELES BUILDING AND SAFE'T'Y s 57�T� >3'N�� /} j ❑ CeAified�ereby furnished. FOR APPLICANT TO FILL IN ADDRESS '4e�—!O L .❑ Certified copy is filed with the county building inspect =04-2-46Z i5 VD tion department. l Zhy .6 �. CITY CI"� L�I ZIP - N AREST ""� mate Applicant - CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT X NOWN LOT CROSS ST. COMPENSATION INSURANCEASSESSOR _ .(This section need not be completed if the permit is for one TRACT d Y"' BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars($TDD)or Cess.) L USE ZONE MAP - I OWNER " . NO. NO. 'I.certify that in the performance of the work for which thisSPECIAL .permit Is issued,I shall not employ any person In any monnet ADDRESS 4CONDITIONS Bo as to become subject to the Workers'Compensation Lawi 19 tJ - CITY K ZIP q1 RE BY O Date Applicant I ARCHITECT OR TEL plSTRIC[ G OUP TYPE 0 -.NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER D CONST. U Exemption, you should become subject to the Workers' ..l a Compensation provisions of the Labor Code, you must forth- ADDRESS ae eat APL CONDO. in :with comply with such provisions a this permit shall be TEL STATISTICAL CLASSIFICATION _ Z R NO deemed revoked. CONTRACTO . LICENSED CONTRACTORS DECLARATION LTG CLASS I hereby affirm that I am licensed under provisions of Chapter 4 ADDRESS NO. SEWEERR MAPWEu. UNITS (commencing with Section 7000)of Division 3 of the Business CITY CLASS � PG. � '23 VALIDATION and P,rafessions Code,and my license a in full force and effect. 54.FT. NO. OF NO.OF CHECK a License Number s y Lic. Class SIZE (S� STORIES FAMiUES ONE —f— Zak �y/ NEW VALUATION512«"55 Contractor* Odd Date r ADD DESCRIPTION OF WORK $ 0 1 am exempt under Sec. ALTER ❑ " A I ITEMS &&P.C.for this reason � CWI� uQ� REPAIR ❑ n TOTAL O,� 5 12.�r� � Date: USE s « r)00, MIK 512.55 EXISTING BLDG. DEMOL ❑ Signature C�lj ,& APPLICANT TEL. FINAL -.00 OWNER-BUILDER DECLARATION (PRINT) NO. DATE - I hereby affirm that I am exempt from the Contractor's License ADDRESS Film t _-Law for the following reason (Section 7031.5, Business and 1 �I1�►I89 Professions code): P - ) BUILDING / 10 1 - A"11:22 131, as owner of the property, or my employees withADDRESS wages as their sole compensation,will do the work and LOCALITY ,'CUL the structure is not intended a offered for sale(Section, TEL _ _ - 7044, Business and Professions Code.) I MOVING - _ V12.rl ❑ 1,as owner of the property,am exclusively contracting', CONTRACTOR NO. ~, � F - with licensed contractors to construct the project (Seo-, ADD 1 ITEMS tion 7044, Business and Professions Code.) -1 _ 12 97 UlREp TOTAL SETBACK FROM I s CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pR . LINE wiD j� T4TAt- J hereby affirm that there is a construction lending agency for' FRONT \.1 171 . 7 the performance of the work for which this permit is issued P.L. {� (Sec.3097,Civ.C.). P.LSID '. ��OV� £ wsf + -.Lender's Nome LDMA Ref.# - Lender's Address - P.C.Fee 055 Permit Fee 1 tJiriJ1 4f 5i/90 • I ceriify that I have read this application and state that the ' IssuanceFee LDMA FJC# ,t 1 An 9.511 above information is correct.I agree to comply with all County Investigation Fee e r - ordinances and State laws relating.to building construction, Total Fee LDMA Perm.# , - and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. , f � y li�a CIJx - �D SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ,