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Home My Public Portal About5546 #101 ROSEMEAD BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION 2Zr;ZDPWi2/a0 M15G1_LLAN17_UUS Ht'1''LII.HI Ivry I he--by aff,;m that 1 have a certificate or consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �l insure,or a certificate of Workers Compensation Insurance.or 1 a certified copy thereof (Sec 3800 Lab C) Policy No Company _ _ FOR APPLICANT TO FILL IN BUILADDIAS O �B HaU LNG AD E89� Certified copy is hereby furnished LOCALITY Certified copy is filed with the county building inspection ci ZIP �,� D NGREST department CROSS ST Date Applicant 91IE OF L NO OF SLOGS TW ON LAT DI[ DNCy P TYF6 C[ea[D BY CERTIFICATE OF EXEMPTION FROM WORKERS TR (I! "P COMPENSATION INSURANCE TRACT BLOCK LAT No rIo ca,c�e� IsTATE MAJOR SECOND LOCAL by is section need note completed l the 100 or lased ASSESSOR MAP BOOK PAGE PARCEL MEZON[ SPECIALCCNDITIONS by the perms a for one hundred dollars 1$100) or less) 1 certify that in the performance of the work for which this OWNER TEL NO permit is issued, 1 shall not employ any person in any manner proper so as to become subject to the Workers Compensation Laws. ADDRESS OCCUPANCY GROUP Date Applicant CIrY ZIP NOTICE TO APPLICANT If after making this Certificate OCCUPANT LOAD ,NOTICE Exemption, you should become subject to the Workers APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code you most forthwith comply with such provisions or this permit shall be deemed TFAiLER USE❑ GEOLOGY INSP ION ElNU Spec KrOWI ❑ revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECT- Panic Demes ❑ 1 hereby affirm that I am licensed under provisions of Chapter +AFET ERMr❑ IST ITEMS BCLOWI 9(commencing with Section 7000)of Division 3 of the Business NO OF EXIT' EJ and Professions Code and my license is in full force and effect ,q�� PARKING REO D PROVIDED License Number Lie Class SPACES Contractor Date LIMITED TIME USE ❑ I am exempt from the licensing requirements as I am 8 mom I DATE TO DATE licensed architect or a registered professional engineer actinmy professional capacity(Section 7051 Business +�:a of Now INSPECTOR 8 g m and Professions Code) n unNG SLOG eroRree SE Lie or Reg No Date PREB WUSE OF BUILDING `'(�1�Q FINAL APPROVAL HOME OWNER-BUILDER DECLARATION No wexiaTINGBUILDINGS DN Lor wND NSE '1 hireby affirm that I am exempt from the Contractor s License Law for the following reason (Section 70315 Business and PtvtessiCode) SD PARKING Ela O PROVIDED V I V ^Ivl �1 1 a9 owner of the property will do the work and th,C�r SPA structure is not intended or offered for sale(Section 70490 PnOPOSED USE OF BUILDING 1io"M Q 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 (See 3(97 Civ C) PROPOSED MAX o C Lender s Name APPLICANTI Wn Ir re 1 - /I r rvJ — �49 `( I../l3` �/. /I b f` Lender s Address ADDRESS ,IV'�/Y''i/ qq 1 b f'b/�%P �Vj,4— G� 1 certify that 1 have read this application and state that the !Xqt evrlPAd vlV #IIJ above Information is COnmCL 1 agree to comply with all County PERMIT FEE ordinances and State laws relating to budding construction and hereby autho,,,JJze relimsentalWes of this County to enter upon I,SUANC[FEE the abov -igfnhoned pr e y for inspection purposes / r1 TOTAL ME $ SEE REVERSE FOR EXPLANATORY LANGUAGE Ignature of Permittee Date