HomeMy Public PortalAbout6235 ROSEMEAD BLVD_Building__ I
WORKERS'COMPENSATION DECLARATION
irertby affirm that I`hove a cettficate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or o certificate of Workers'Compensation Insurance,
org.certified copy thereof (Sec. 3800, Lab. C.)
�r COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company BUILDING'
❑ Certified copy is hereby furnished. ; FOR APPLICANT TO FILL IN ADDRESS 3,6
\ ��4t 7�1=f7�b v 1 L�
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDIRESS T— DL /
Date Applicant CITY i� ,� j/��1p/ ZIP !!?1700 NO.OF BLDGS. pLOCALITYI % (,'� zS ./ -
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZEEIOF LOT ,1. 491y JIM, NOW ON OT 1 CROSS STNEAREST I '- IV,6
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) [AD
CT BLOCK 11 LOT NO.EL, lj1 MAP BOOK PAGE PARCEL
OWNER r� c)Yb NO.J��`U USE Z NE MAP
I certify that in the performance of the work for which this _ NO.
permit is issued, I shall not employ any p rson iponmanner L! � V !�P�'�'f 5 SPECIAL
so as to become subject to the Workers' s. RESS C9Njl� � ZIP eDate V Applicant HITECT OR p TEL.-�• y, c�+ DISTRICT GROUP TYPE FIRE POCESSED BY
NOTIE TO PPLICANT: If, after m ii g thisof INEER leb) r�l> NO.�77(� I �JG _/ CONST. ZONE
Exemption, you should become subject to the Workers' /- UF( �� -
Compensation provisions of the Labor Code, you must forth- RESS O,�'S t3 G y� tU
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFIC TION APT. NDO,
deemed revoked. TRACTOR NO. '
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS
_±L_
hereby affirm that I am licensed under provisions of Chapter 9 RESS NO. SEWER
(commencing with Section 7000)of Division 3 of the Business and /l) LIC.
Professions Code, and my license is in full force and effect. v CLASS BK VALIDATION y?
FT. a NO.OF c NO.OF CHECK "j ALicense Number Lic.Class 1� STORIES G. FAMILIES ONE
VALUATION ///, �7� # ooo•o `23
Contractor Date CRIPTION OF WORK :' /r _ Y NEW
❑ ; X /,. .L[1 U O
❑I am exempt under Sec. L r f 1 (J I/ l 6, , I o 5 5 a 4 5
_ LTt ALTER ❑ LLI
B.BP.C. for this reason L2 h� --,, ' u REPAIR ❑ $ - 55R450' O'
Date: USE OFCn
��_ _ - DEMOL ❑ Z
EXISTING BLDG. I a3 1 —88
Signature M APPLICANT �� TEL. /71' FINAL I
OWNER-BUILDER DECLARATION PRINT -L � -�-N�O. yBjG�G 7 DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESS�1�C. �� 1 G�f/-5G C/�L FINAL
Low for the following reason (Section 7031.5, Business and
P f ssions Code): w PRESENT BY ?,.1� c. , -c:,
BUILDING V
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale Section LOCALITY ' 11 LI �.—
( TEL. I: ..._ r -. �.`:,L
7044, Business and Professions Code). MOVING i
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. CK 1 4`-s}._;I�
with licensed contractors to construct the project (Sec- i �»C j I
tion 7044, Business and Professions Code).
ADDRESS t.jJr;�i�3G c�-Il.
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK
i SET BACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT r -rs
the performance of the work for which this permit is issued P.L. 'II-t�'Y-'''�'�= �'� =f'-'
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name LDMA Ref. #
o ;P.C. Fee$ 6 5 (! c Permit Fee
Lender's Address
lop.I certify that I have read this application and state that the Issuance Fee LDMA P/C#
above infor at'on is correct. I agree ro comply with all County Investigation Fee
ordinances nd State laws relatin to building construction, Total Fee CDMA Perm. #
and here y'out
isenta ves of this County to enter
upon the ovP1pp t for inspection purposes.
g es
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of icant or gent D
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