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Home My Public Portal About5500 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATIUNUECLARAIIUN ao-ooe3CPwlara0 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 7 I +unuq or a certJcate of Whiten'Compensation Insurance,or , i a certified copy thereof(Set 3900 Lab.C) Policy No, Company FOR APPLICANT TO F1LL W � 8 Certifwd copy a hereby NmLshed 3 6 tj Cemfred copy is filed with the county budding inspection ZIP S I department I N[ARur atou sT Date % Applicant SIZE OF LOT NO OP a'DG NOW ON LOT DrnTRreT ND GROUT 1YR rRoc[asED err G CERTIFICATE OF EXEMPTION FROM WORKERS C r COMPENSATION INSURANCE TRACT BLOCK LOT NO .Y. wm,ror (, (This section Deed not be cum leted if the work involved "iD � � RATE YA.r0r1[[GOND LOLL P ASSESSOR MAP BOOK PAGE ZTJ ARCEL I by the permit u for Doer hundred dollen (51001 or less.) un[zaere nP6C1AL CDNDRgNs I Bendy that in the performance of the work for which this err D permit is issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws ADo s OCCUPANCY GROUP v Date Applicant Crry ZIP NOTICE TO APPLICANT If after making this Certificate OCCUPANT LOAD of Exemption you should become subject to the Workers APPLICATION FOR Compensation provisions or the Labor Coda you must forthwith EXIT HARDWARE comply with such provisions or this permit shall be deemed TRAuaR tis,❑ GaO ywa►[crtoN❑ NO Spec Knowl ❑ ' rooked LICENSED CONTRACTORS DECLARATION °Ce1eAfrev�' GT1O1'� Penn Devices ❑ I hereby affirm that 1 am licensed under provisions or Chapter ,Ar[Tv rERYr❑ tuar rtEwa aEl.owi 9(commencing with Section 7000)of Division 3 of the BusinessO P.88 Mo or QiTE and Professions Code and my license is in full force and effete MHK1N6 R[O'D PROVID[D i License Number Lic Class � arvicea I Contractor Date LIMITED TIME USE ❑ 1 am exempt from the licensing requirements as 1 am a DAT[ DATE licensed architect or a registered professional engineer TROY To acting in my professional capacity(Section 7051 Business a'�art No or iNePeeroR a ' and Professions Code) QiET[ri6 aLna artom[a niearATURa. Lie or Re& No. Date ^renEirT unci or euu_01 a FINAL APPROVAL p 6 3 ' HOME OWNER-BUILDER DECLARATION NO or au Imz 1 tar+IAT AND usa I hereby affirm that 1 am exempt from the Contractors Litems Law for the following reason (Section 70315 Business and Professions Code) ND MRKiNG i ❑ I as owner of the property will do the work and the nr "rnovioao l structure is not intended or offered for sale(Section 7044 3 r POEM uaE or autwiN Business and Proresstom Code) i CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for ( v the performance of the work for which this permit is issued i (Sec 3097,Civ C) ►nwosED YAx act I leaders Name ArruCANT crani T NO gzgJ Lender s Address Ern 1 certify that I have rail flus application and state that the I ool above information IS correct. I agree to comply with all County nRMR me I ordiDaoces Soil State laws relating to budding comtruction and hereby authorize representatives of this County to enter upon uniA+acE raze - i- ,I the above-mlimIguied property for inspection purposm -- - - ;' I A" I TOTAL R[ % 7 I 6170 SEE REVERSE FOR EXPLANATORY LANGUAGE Sisnatum of Permittee Date WORKERS'COMPENSATIONDECLARAnON TZ��,1Zr90 MISCELLANEOUS APPLICATION I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �insum or a certificate of Workers'Compensation Irismance,or (� a certified copy thereof(Sed 3800 Lab.C) - Policy Na Company FOR APPLICANT TO FILL IN auitalNG I 8 BUILDING ADDRESS ADDREDS , Certified copy Is hereby furnished ,5soo )✓ QoSew,,L � g L rJ LOCALm. 1 �Certeified�copy is filed with the county building Inspection erwt. r� G ZIPNUREST OO cwwa ar ' Date Applicant SIZE OF LOT No OP W DGS NOW ON LOT DtfTR,CT IVD GnOUP Tvvs IaROC[afan BY 136 CERTIFICATE OF EXEMPTION FROM WORKERS coNzr V 1 I COMPENSATION INSURANCE MACT BLOCK LOT NO �+� ,• MO ,CN6.[I RATE MAJOR SECOND LOCAL (This section need not be completed If the work Involved ASSESSOR MAP BOOK PAGE PARCEL I by the permit Is for one hundred dollars (5100) or less.) eE zoNa SPECIAL co«ortwNs L 0 — r C 1 I certify that m the performance of the work for which this TEL NO S GoT I permit Is Issued I shell not employ any person in any manner a so as to become subject to the Workers Compensation Laws. ADDS ss�o Q-oS-r- tit � , Z OCCUPANCY GROUP ( , Date Applicant CITY„ zip NOTICE TO APPLICANT If after making this Certificate I L< C 9/ OCCUPANT LOAD of Eumption you should become subject to the Workers APPLICATION FOR Compensation provistoru of the labor Code.you must forthwith EXIT HARDWARE ( comply with such provisions or this permit shall be deemed TRAILER USE ototaov'Ns"CT1oN❑ (4p gpge Kriowl ❑ revoked LICENSED CONTRACTORS DECLARATION occumNcY INSPSc ,oNPanic Devices ❑ 1 hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERM ❑ (UST rEMS 06Losv) •EJ I I 9(commencing with Section 7000)of Division 3 of the Business O P.HB NO OF[xm and Professions Code and my license is In full force and effete game License Number Lit Class PARKING Reo D movlD[D I i-� 4 � .�., arACEa ( I I Contractor Date LIMITED TIME USE ❑ 1 am exempt from the licensing requirements as 1 am a mom DATE TO DATE licensed architect or a registered professional engineer acting in my professional capacity(Section 7051 Business size or No or oroPECTGR a '( and Professions Code) ntiSTING BLDG sroarca SIGNATURE. Lic or Reg Na Date PRESIEW USE or BUILDING FINAL APPROVAL z + HOME OWNER-BUILDER DECLARATION NO or"IJFTI GniRLDUNos I ON LOT AND USE 1 hereby affirm that 1 am exempt from the Contractor s License Law for the following reason (Section 70315 Business and 1 Professions Code) No PAnIfIIJG ❑ 1 as owner of the property will do the work and the SPACES PRovIDaD i structure is not intended or offered for sale(Section 7044 1 PROPosaD use or nu)LD,No M Business and Professions Code) t i CONSTRUCTION LENDING AGENCY I hereby affirm that there a a construction lending agency for the performance of the work for which this permit Is issued ( i (Sec 3097,Civ C) PRoi•oeaD rex ace Lenders Name AIM NT JIWT) TELNo Lettders Address A M " '� /3 3a 9a 90o ( I 1 certify that 1 have read this application and state that the ' above information Is correct I agree to comply with a0 County MJtMr ME I ordinances and State laws relating to building construction and I hereby authorize representatives of this County to enter upon issuANcs me tS the above-mentioned property for inspection purpose ( I i % SEE REVERSE FOR EXPLANATORY LANGUAGE f s1zhiture of Permittee Date