HomeMy Public PortalAbout6202 ROSEMEAD BLVD_Building__ A)RKEBS'COMPRNSATION DECLARATION .t, -
ffirbn thci I have a certificate of consent to self APPLICATION R S I L®I PERMIT
� v aS•�
y certificate of Workers'Compensation Insurance,
or ?opy thgreof(Sec,, 3800, Lab. C.)
Folic '` Com un COUNTY OF LOS ANGELES BUILDING Abd® FETY
Y ",, P Y 6 .-�,... ,..:.. ..
Ceti led copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
,•:ADDRESS &g940.2. flouote.,oq
Certified copy is filed with the county building inspec- BUILDING -
tion dep �rfmOnt. /� p ADDRESS G
Date Applicant /Y _.,�r^ CITY �— _ ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' JNo.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT Id B NOW ON LOT �- "CROSS ST.
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. ASSESSOR
64
hundred dollars($100)or less.) }MAP BOOK PAGE PARCEL
TEL. U ZO MAP
I certify that in the performance of the work for which this OWNER j lrz NO. $b'��b MA v
permit is Issued,I shall not employ any person in any manner ADDRESS - , S SPECIAL 0
so as to become subject to the Workers'Compensation Laws. CONDITIONS
Date Applicant CIN Jr L F Q eT ZIP
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE -PROCESSED BY 0
Exemption, you should become subject to the Workers'
ENGINEER NO. sa NST, E
Compensation provisions of the Labor Code, you must forth- ADDRESS `�
with comply with such provisions -or this permit shall be TEL.'7A STATISTICAL CLAS C ION APT. CONDO. N
deemed revoked. CONTRACTOR -� NO. �.1.
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS &� 6 SIS' NO.
(commencing with Section 7000)of Division 3 of the Business and LIC.
rofessions Code,and my license is in full force and effect. CITY CLASS e1 a1 - VALIDATION
,4� ] SQ. NO.OF NO.OF CHECK
License Number Lit.Class r" ` SIZE , STORIES a FAMILIES ONE a
VALUATION �;}>
Contractor LCMA4A CLar/`tti L�`Date 2'64?"7 DESCRIPTION OF WORK - NEW $ ®
_ ADD
I am exempt under Sec. ALTER
B.BP.C. for this reason
REPAIR
a 6 USE OF Q L
Dote: EXISTING BLDG. ,J-� 1 r DEMOL ❑
Signature 4- v - APPLICANT TEL. W ; FINA
OWNER-BUILDER LARATION L> PRINT NO. O1 DATE
I hereby affirm that I am exempt from the Contractor's License E'er
Law for the following reason (Section 7031.5, Business and ADDRESS ° s3 FIN _r
Professions Code): ENT e4
BUILDING -
I, as owner of the property, or my employees with ADDRESSyY'' tiT
wages as their sole compensation,will do the work and ezr
the structure is not intended or offered for sold(Section LOCALITY 3, UBE,
7044, Business and Professions Code). MOVING TEL.
I, as owner of the property,am exclusively contracting CONTRACTOR NO. a "yj3j- 134a251
with licensed contractors to construct the project (Sec- ADDRESS r' '
tion 7044, Business and Professions Code). HEC
�
REQUIRED TOTALS
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
1 hereby affirm that there is a construction lending agency for FRONT B ® ,
the performance of the work for which this permit is issued P.L. U
(Sec. 3097, Civ. C.). SIDE
P.L. (/ Lj_iriJ"'`I1L)I
Lender's Name j t AN 11,LDMA Ref. fi ..„,i ,, r
s P.C.Fee$ Permit Fee LD
•
Lender's Address
I certify that I have read this application and state that the Issuance Fee ® ° LDMA P/C R
above information is correct. I agree to comply with all County Investigation Fee `
ordinances and State laws relating to building construction, Total Fee LDMA perm. li
and hereby�authortze representatives of this County to enter
upon the above-mentioned property for inspection purposes.
' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date