HomeMy Public PortalAbout6162 ROSEMEAD BLVD_Building__ ) S'CQMPEf ZA ION DECLARAiTION {
nsure�,y affirm that I ha0e ce'C mte of consent to self APPLICATION FOR BUILDING PERMIT
nsurei or'a certificate of Workers'Compensation Insurance,
For a',certified copy thereof(Sec. 3800, Lab. C.)
c-� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No ®�� Lcompany �' ��(P�(ril� BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
yrs Certified copy is filed with the county ilding inspec- BUILDING c
�{ieD department. ADDRESS Nr Q LOCALITY
NEAREST
DateJRT1'FI
Appliccm CITY IW-L ZIP CROSS T. a
TE F EXEMPTION FROM WORKERS' ' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT DC�L NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP i� 2
hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO. V J
TEL. SPECIAL
I certify that in the performance of the work for which this OWNER /.G- NO. CONDITIONS
permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE P CESSED BY
r� n� 1 k-31 . / ZONE
so as to become subject to the Workers ADDRESS CONST
Compensation Laws. U ISI/ 19Date Applicant CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. U
'Exemption, you should become subject to the WorkersENGINEER 1 NO. CLASS NO. DWELL. UNITS LULU
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall be ; Z
deemed revoked. TEL' BK. PG, VALIDATION
_ CONTRACTOR Q� NO.
LICENSED CONTRACTORS DECLARATION IC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1� NO. r VALUATION II7�l'�t�� ! I�
(commencing with Section 7000)of Division 3 of the Business and LIC 7
Professions Code,and my license is in full force and effect. CITY L R3 CLASS $
//�� ���� SQ.FT NO.OF NO.OF CHECK
License Number �' Lic.Class_,84 SIZE STORIES FAMILIES ONE
Contract Date ! DESCRIPTION OF WORK NEW
$ ( ° 4 0 3 5 5
I am exempt under Sec. t�"V 1 P� �CNd- ❑ s
p LTER ❑ FINAL ° ° 4 0 3,5 5
B.BP.C. for this reason DL1XA'+C•JA9 �/�—� DATE /�
REPAIR ❑ 10, 17-84
USE OF
Date' EXISTING BLDG. V W 6:n_ DEMOL ❑ FINAL
Signature APPLICANT jr TEL. y
OWNER-BUILDER DECLARATION PRINT r ^ A �/ NO.' IQ
I hereby affirm that I am exempt from the Contractor's License ADDRESS S. L.�er> C c7 r ® ;90959A
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT # a 0 0 0 2 3
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS f a o4.590
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section [ADDRESS
CALITY
7044, Business and Professions Code). OVING TEL. ° 004S90?,
❑ I, as owner of the property, am exclusively contracting NTRACTOR NO. :
with licensed contractors to construct the project (Sec-' Q25-84
tion 7044, Business and Professions Code). EQ ED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY ET BACK YARD HWY PROP.LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT L
the performance of the work for which this permit is issued , P.L.
tSec. 3097, Civ. C.). SIDE
/ P.L. ;20960A
Q Lender's Name d/ILS yy�� C�'
IP.C. Fee$ V&S,'5 - 26175- # 0 o ° 0 0 7
Lender's Address LL
Permit Fee
r I certify that I have read this application and state that the I Issuance Fee 1 ®F � 053925'
above information is correct. I agree to comply with all County I e
ordinances and State laws relating to building construction,' Total Fee 3 �� 7
and hereby authorize representatives of this County to enter
upon the a ve-mentioned property for inspection purpos ° ° 5 3 9,2 5 61
rj SEE REVERSE FOR EXPLANATORY LANGUAGE
®s
azure of Applicant or Agent a .
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