HomeMy Public PortalAbout5546 #203 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION z 12,90 MISCELLANEOUS APPLICATION -
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING AND SAFETY DIVISION
•msum or a certificate of Workers'Compensation insurance.or - U
a certified copy thereof(Set. 3800 Lah C) '
Policy No. Company �§ '08 APPLICANT TO FILL IN BulILfNG
i BADoweas
Certifred copy Is hereby furnished.
Certified copy is filed with the county budding Inspection
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I department 2 C,: Caoo:r
Date Applicant SIZIEOF LOT Wo OF BLDGS NOVI ON Lor deTRK:T No GiTTPE PleoeEee®ev d
CERTIFICATE OF EXEMPTION FROM WORKERS 2,1— i011P
y� caur
I COMPENSATION INSURANCE TRACT BLOCK I LAT NO Wever U
w ,OwCLn arAT[MAJOR SECOND Lout_
(This section need not be completed If the work Involved ASSESSOR MAP BOOK PAGE PARCEL
by The permit isfor one hundred dollars ($100) or less.) use zoN[ srwAL coNomONa
I certify that in the performance of the work for which kiss r � TEL NO
I permit is Issued I shall not employ any person In any manner y
so as to become subject to the Workers Compensation Laws. AO°RES9 OCCUPANCY GROUP in
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Date Applicant air 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 must forthwith EXIT HARDWARE
comply with such provisions or this permit shall be deemed TRAILER usa❑ GEOILGT INaPECr N❑ No Spec Knowl ❑
revoked EloccuMNcr 1m%FecmoN Panic DBVICes
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter sA irry PERMIT❑ war rrcMs Mi-ow)
i 9(commencing with Section 7000)of Division 3 of the Business I SaW ot Bus,,,�s NO OF EXITS
and Professions Code and my license is in full force and effect
License Number Li Class Q(.7 lw 'PARKING RCOo PROVIDED
SPACES
I l Contractor Date UMITED TIME USE
❑ I am exempt from the licensing requirements as I am a FROM DAT[ TO DAT[
licensed architect or a regstered professional engineer
acting m my professional capacity(Section 7051 Business oneT°IF aLDO aro or 15FESIGK.
and Professions Code)
Luc or Reg. Na RI
Date ME 14EW USE Of eUIL Q FINAL APPROVALL710 3LA
HOME OWNER-BUILDER DECLARATION No wJOrsnnG eulLwnw
� ON LOC AND ucE
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 70315 Business and
Professions Code) NO MRKING
❑ I as owner of the property will do the work and the 'PACES PROVIDED
structure is not Intended or offered for sale(Section 7044, PRO=use OP eUnDING
Business and Professions Code)
i CONSTRUCTION LENDING AGENCY _
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued '
i (Sec 3097,Civ C) rpol+oeED MAX ace
Lenders Name AIPLIGANT rrmvrl T[L No
e Lr 7
Lenders Address ADoaus
I certify that I have read this application and state that the
above information is correct I agree to comply with a0 County P[pMrr I'E[
ordinances and State laws relating to building construction and
hereby authorize representatives of this County to enter upon meuANc[Pee
I t i the above-mentioned property for Inspection purposes
Tarot P[c
% /— 'ls� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Penninee Date