HomeMy Public PortalAbout5541 ROSEMEAD BLVD_Miscellaneous__ t , WORKERS'COMPENSATIONDECLARATION z�„rt„90 MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
unsure,or or a certificate of Workers'Compensation Insurance, or �J
a certified copy thereof (Set, 3800 Lab.C)
(� Policy NO CompanyA,4y FOR APPLICANT TO FILL IN eu,LOao
8
BUIL NG ADORES ADDREss
Certified copy is hereby furnished.Z 4v"" t �l,k'.1
t Certified copy is filed with the county budding inspection a nP I
NeARnT
department (''� I CROSS sr l\S
' Date ' ' Applicant—SI S (1__ SIZE OF LOTI NO OF ON LOT paTmCT NO I GROUP I TYPE PROCESSED eY >'
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CERTIFICATE OF EXEMPTION FROM WORKERS TRACT BLOCK LOT NO oNsr O
COMPENSATION INSURANCE,
ND ICiRCL[l IiTATE MAJOR SECOND LOCAL
(This section need not be completed if the work Involved ASSESSOR MAP BOON PAGEPARCEL DSE rONE SPECIAL CONDITIONS 1=by the permit is for one hundred dollars 1$100) or less) 9
A 1 I certify that In the performance of the work for which this r e TELNO
permit is issued I shall not employ any person in any manner — 0 0
so as to become subject to the Workers Compensation Laws ADDRESS
OCCUPANCY GROUP Z
( Date Applicant
NOTICE
ZIP
NOTICE TO APPLICANT If after making this Certificate OCCUPANT LOAD
of Exemption you should become subject to the Workers APPLICATION FOR
Compensation provisions of the Labor Code you mint formwnh EXIT HARDWARE
( comply with such provisions or this permit shall be deemed TRAILER Me El GEOIAGv,NSPECTiON❑ No Spee Knowl ❑
revoked
LICENSED CONTRACTORS DECLARATION occumN v INSPCCrwN(I Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETYPERMIT❑ (L,STmEMSBEL )
1 , 9(commencing with Section 7000)of Division 3 of the Business aim0 o eHs No or Extra
and Professions Code and my license is,n full tome and effect
PARKING RED D D PROVIDED
License Number c.
Lic Class _ =4 SPACES
t i Contractor Date LIMITED TIME USE
DATE DATE
FROM❑ I am exempt from the licensing requirements as I am a To
licensed architect or a registered professional engineer
(
act uig in my professional capacity(Section 7051 Business Ase of NO or vtsPECTOR S
and Professions Code) EG xISTINECoG ,j' STORIES s ATURE.
Lic or Reg No Date PRrxNT ME oP auil�iNe T FINAL APPROVAL
i HOME OWNER-BUILDER DECLARATION NO Or ocumwc auiLaNca
ON IAT AND IRE
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 70315 Business and
1 Professions Code) NO PARKING
SPACES PROVIDED VIC bcltk
❑ I as owner of the property will do the work and the
structure is not intended or offered for sale(Section 7044 2 PROPOSED USE OF a IWING
I
Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
t
Sec 3(197, Civ C) PROPOSED MAX OceRa
oder s Name APPLrTT ierivri TEL No
Lender s Address ADDRESS
( I certify that I have read this application and state mat the
above information is correct I agree to comply with all County PQyixrt Pee
I ordinances and State laws relating to budding construction and
hereby authorize representatives of this County to enter upon ,,,,Nce FEE
the above-mentioned D erty for inspection purposes
- I TOTAL F[6
% } , 0 VtAAL SEE REVERSE FOR EXPLANATORY LANGUAGE
Isnaturc of Perm,uee Duce