HomeMy Public PortalAbout5546 #201 ROSEMEAD BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION 'o0063oPsv12/90 MISGELLAIVtVUb Ht'1''LltrHl IVIV
1 hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure,or a cemfrcat. of Workers Compensation Insurance.or
a certified copy theeot (See 3800 Lab C)
Polies No. Company FOR APPLICANT TO FILL IN BUILDING �j� '
EB ADORES
C Ifled copy Is hereby furnished — LacALnr
ertdted copy Is filed with the countyAuil ng Inspection CITY I
fFICATE
cit N"REST
VZ� cROW5 ST
DaApplica SI o LOT OF B NOW ON LOT p�'D� GRyDP TYPE CEaeeO BY
bf�i 6/.'( coNRT
OF I N FROM ORKERS
COMPENSATION INSURAN E TRACT BLOCK LOT No
!TATE MAJOR SECOND LOCAL
(This section Reed not be completed If til work Involved ASSESSOR MAP BOOK PAGE PARCEL ME SONE sPeCIAL CONDm10NS
by the permit is for one hundred dollars ($100) or less)
I certify that in the performance of the work for which thisWTER
O 2Lt z121, r
permit is Issued, 1 shall not emplo) any person in any manner
so as to become subject to the Workers Compensation Laws ADR OCCUPANCY GROUP
r
Date Applicant 9TV
INOTICE TO APPLICANT If after making this Certificate OCCUPANT LOAD
of Exemption, you should become subject to the Workers APPOCATI N FOR
Compensation provisions of the Labor Code you must forthwith EXIT HARDWARE
comply with such provisions or this permit shall be deemed TRAILER ME❑ GEOLOGY INSPEcr ❑
revoked No Spec Know) El
OCCUPANCY INSPECTION❑ Panic Devices E]LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter SAFETYP "rrEl (LIST ITEMS eELOWI
9(commencing with Section 7000)of Division 3 of the Business No OF"as E:1i
and Professions Code and my license is in full force and effect
PARKINGE:1
D E= PROVIDED
License Number Lic Class ePAces
Contractor Date LIMBED TIME USE
1 Erni exempt from the licensing requirements1 alit a DATE DATE
PROM TO
licensed architect ore registereddprofessional
all engineer
acting in my professional capacity(Section 7051 Bminess aIzE OF NO OF INSPECTOR e
end Professions Code) "WING eLDG STORIES ATURE,
Lic or Reg No. Date PRESENT USE OF BUILDING FINAL APPROVAL _
HOME OWNER-BUILDER DECLARATION OF EXIfaING Buft-DINds O
oN LOT AND use
I hereby affirm that I am exempt from the Contractor s License V
Law for the following reason (Section 70315 Business and r
Professions Code) YO PARKING �l
El 1 as owner of the property will do the work and ihQ� SPACESPRov zD
structure is not Intended or offered for sale(Section 7(bf4pL PROPOSED USE OF BUILDING
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
(Sec. 31197 Civ C) 6D MAx OCG
Lenders Name wPPuuNr lPwrrl rel No
Lenders Address ADDRESS
1 certify that 1 have read this application and state that the
above Information is correct. 1 agree to comply with all County PE ff FEE
ordinances and State laws relating to budding construction and
hereby authorize representatives of this County to enter upon reSuANce FEE
the abov -mentioned props for Ins action purpo
i
TOTAL Fee
= SEE REVERSE FOR EXPLANATORY LANGUAGE
g F.0 of y ntee Ic