HomeMy Public PortalAbout6156 ROSEMEAD BLVD_Building__ offffIr that APPLICATION FOR BUILDING PERMIT
I heretby affirm tlSat 1 hove a certificate of consent to self
s, insure, or a certificate o€Workers'Compensation Insurance,
or.o certified copy thereof(Sec.3800, Lots. C.) �� COUNTY OF LOS ANGELES � BUILDING AND SAFETY
Policy No. 012 Company S��TE �N
Gerlified copy is hereby famished j}
y--� FOR APPLICANT TO FILL IN ADIDLRIESS 4 _&1 Q
LJ
❑ Certified copy is filed with the county building inspec- BApp 2"' LID
tion department. CITY �t f
� ZIP LOCALITY
Date_.I� Applicant LA 0 M • - `
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT ?< KNOW ON LOT CROSS ST.
COMPENSATION INSURANCE � ASSESSOR I
(This section need not be completed if the permit is for one TRACT B Y4 BLOCK LOT NO. 0 MAP BOOK PAGE PARCEL
hundred dollars($100)or Tess.) TEL
OWNERNO. USE ZONE MAP
:1 certify that in the performance of the work for which this SPECIAL a
permit is issued,I shall not employ any person in any manner ADDRESS CONDITIONS C)
so as to become subject to the Workers'Compensation Laws. /� U
CiTY 1�• ZIP l Ix
Date Applicant ARCHITECT OR TEL DISTRI GROUP ITYPE FIRE CAE PROCESSED BY Q
.NOTICE TO APPLICANT: if, after making this Certificate of ENGINEER .NO 3'3+v r✓ CONST. V
jL
Exemption, you should become subject to the Workers' {J1 13 • eA 0-
Compensation provisions of the labor Cade,you must forth- ADDRESS 3'af0 a
with comply with such provisions or this permit shall be CONTRACTOR NO STATISTICAL CLASSIFICATION APT• �N� 4 Z
deemed revoked. CLASS NO. UNITS
LICENSED CONTRACTORS DECLARATION LIC'
I hereby affirm that 1 am licensed under provisions of Chapter 4 ADDRESS LIC. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business CLASS VALIDATION
and Professions Code,and my license is in full force and effect. CITY _BK. PG. _ '
SQ.IZ ET./ NO OF NO.OF CHECK w aTr w
License Number�y Uc.Chris ^� SIZE ! STORIES FAMIUES ONE VALUATION tMbb i s♦ ��r.'yy.
t7 I DESCRIPTION OF WORK NEW !W -512.55
-�'D tl1 Date M 1 ITM
Contractors _.
❑1 am exempt under Sec. A v _ ALTER ADD ❑ �tT� 1 ;55
B.BP.C.for this reason OWN u�E REPAIR ❑ $ ` �L-l�
to: U STNG BLDG. DEMOL ❑ 4 0 b 512.55
APPLICANT TEL. FINALPRINT? AD
Signature i
C
g OWNER-BUILDER DECLARATION NO. DATE
I hereby affirm that 1 am exempt from the Contractor's License ADDRESS - FINAL f
Law for the following reason (Section 7031.5, Business and f of I �
Professions Code): PRESENT -- By '_ wit 22
BUILDING � - •�,�� 1 �tt�i�i:
❑ I, as owner of the property, or my employees with ADDRESS __
wages as their sole compensation,will do the work and LOCALITY ��, -
the structure is not intended or offered for sale(Section _ _ ACCT='t
7044, Business and Professions Code.) �NTNRACTOR TEL
{7 172.7 r
❑ 1,as owner of the property,am exclusively contracting . —.1
with licensed contractors to construct the project(Set I ADDRESS 1 ITEWS ,
tion 7044, Business and Professions Code.) ° • i ' __
CONSTRUCTION LENDING AGENCY i QBA YARD HWY TOTAL SE BAC E ROM EXIST, �/ _ TOTAL
1712.'97
1 hereby affirm that there is a construction lending agency for' FRONT ' �, IECY, I7�.
the performance of the work for which this permit is Issued P.L.
(Sec. 3047,Civ.C.). `SIDEiE�I
_ _ _ P.L.
Lender's Name i —
^- _ LDMA Ref.A
P.C. Fee$_ r✓ Permit Fee - nrltti k. i 4/ 45/90
Lender's Address ) (�' 4AJu��
1 certify that I have read this application and state that the 01` j issuance Fee LDMA P/C q 7 i AM 9:50
- above information is correct.I agree to comfly with all County Invesllgarton Fee _ _ _
ordinances and State laws relating to but ding construction, Total Fee LDMA Perm. 0
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes. _i
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date