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Home My Public Portal About5546 #205 ROSEMEAD BLVD_Miscellaneous__ 70M4 ! WORKERS' COMPENSATION DECLARATION 20-0Oe3DPW12/90 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ms=or a certificate of Workers'Compensation Insurance, or (� a certified copy thereof(Set 3800 Lab. C) - ' Policy No. Company FOR APPLICANT TO FILL IN BUILOING 11=?1317/ 6 ADDREIa Certified copy a hereby furnished G pS" gqy 3C -11'") 05- LOCA,LrrY Certified copy is filed with the county building Inspection ciTT ZIP NEARSST i I departmentFl1PCE f/ 9/780 Dross ST Date Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT oIfTRiCT NO GROUP TYPE PROcaaam BY d CONST CERTIPICATE OF EXEMPTION FROM WORKERS TRACT BLOCK LOT NOO ( I COMPENSATION INSURANCE M Icwasi STATE MAJOR SECOND LOCAL (This section need not be completed If the Work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONOrriONS by the permit ts for me hundred dollars ($100) or less I 0 ( I certify that in the performance of the work for which this H T eu C3'Off-A/ 75 ! TEL L-�r—jlat+t permit is issued I shall not employ any person In any manner o ! SO as to become subject to the Workers Compensation Laws ADDRESS o S FiRSr AI/✓c OCCUPANCY GROUP N Z ( Date Applicant CITY ZIP _ NOTICE TO APPLICANT If after making this Certificate AfC:ADl� 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 use❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑ revoked LICENSED CONTRACTORS DECLARATION ocCUPANcY INsmcnoN[J Panic Devices ❑ 1 hereby affirm that 1 am licensed under provisions of Chapter sAFerr PsaMrt❑ ILISTaT SBELOW) I i 9(commencing with Section 7000)of Division 3 of the Business aMe UB ess NO OF,eXms and Professions Code and my license is In full force and effect PARKINGREO O � ryrpylDEO i License Number Lie Class aPAcltsas ( I Contractor Date LIMITED TIME USE ❑ I DAT[ DATE FROM am exempt from the licensing requirements as I am a To licensed architect or a registered professional engineer ( acting in my professional capacity(Section 7051 Business MZE of NO OF WSPECTOR a and Professions Code) EXISTING BLDG srmlmi SIGNATURE Lic or Reg No Date PRESENT USE OF BUILDING FINAL APPROVAL HOME OWNER-BUILDER DECLARATION NO OF EKISTING aDILDINGS ON LAT AND USE 1 hereby affirm that I an exempt from the Contractor s License Law for the following reason (Section 70315 Business and ( Professions Code) NO PARTING , ❑ I as owner of the property will do the work and the SPACES PROVIDED structure is not intended or offered for sale(Section 7044 1 PROPOSED USE OF BUILDING Business and Professions Code) j CONSTRUCTION LENDING AGENCY /KLUVjVT( !V(OIYS 7At PRE ABA IDN I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ( , (Sec 3097 Civ C) PROPOSED MAX xe A/J Lender's Name APPLICANT flT ) wu PAtV UIV6—afb" Lenders Address ADDRESS ( I 1 certify that I have read this application and nate that the *,l 9 "tiA AvE 7 r'7 c cirf e,.i yl,7.*b above information is correct I agree to comply with all County PERM,FEE I ordinances and State laws relating to building construction and hereby authorize representatives of this County to enter upon ISSUANCE ME the above-mentioned property for inspection purposes - t 1 TOTAL FEE a/ ' tV� ✓� SEE REVERSE FOR EXPLANATORY LANGUAGE �� Signature Of Pem,ntee Date WORKERS CUMPCINNAILUIN UCLLAKA WN 20-00e3aPW12/90 IVII��.�L,LHIYGVV.7 HrrL.gt.r►a ays� I hereby affirm that I have a certificate of consent to self COUNTY OF O -ANGELES BUILDING AND SAFETY DIVISION Kmsuret or a certificate of WOi'kers' Comperuation losmance,or a cerofied copy thereof (Sec. 3800 Lab.C) ;-.+-• Policy Nn Company FOR APPLICANT TO FILL IN BUILDING i BUILD NG ADD 8 p� �.J AODREas I 8 Certified copy is hereby furnished V1W[ 6 LcuLrry Certified copy is filed with the county building InspectionC n ZryIP `� NEAREer I department v� V`�� bl.+ CROSS ST ' Date '' Applicant SIZE OF OT NO OP auiw NOW oN LDT OIBTRKT NO GROUP TYPE PROCESSED BY d CERITFTCATE OF EXEMPTION FROM WORKERSCONST Q COMPENSATION INSURANCE TRACT BLOCK LOT NO MAP ,d�iwAY w ICIKCL[I STATE MAJOR fELOND LOCAL (This section need not be completed If the work involved ASSESSOR MAP BOOK PAGE PARCEL by the permit is for one hundred dollars ($100) or less.) USEXONE ISPECIALCON01110145 I certify that In the performance of the work for which this a TEL No permit is issued I shall not employ any person in any manner y so as to become subject to the Workers Compensation Laws R aAVCOCCUPANCY GROUP Date Applicant C 'PI NOTICE TO APPLICANT If after making this Certificate —1 OCCUPANT LOAD of Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code you mot forthwith comply with such provisions or this permit shall be deemed r,A,L RusE❑ oEouaaY INSPEtrnoN❑ �� KrXiw4 ❑ revoked ❑ ' OCCUPANCY INSPECTION( Panic Devices LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter SAreTY PERMIT❑ (LIST rrEMS BELo ) f� 9(commencing with Section 7000)of Division 3 of the Business �e o ase No or eXrrs and Professions Code and my license Is In full force and effect PARKING REDID PROVIDED I.Icense Number Lic Clan AVIUAl1 SPACES I Contractor Date LIMITED TIME USE 1 - I El I erii requirements exempt from the licensing regments as i ca DATE licensed architect or a registered professional engineer FROM DATE acting in my professional capacity(Section 7051, Business Sits OF No or wSPEerona and Professions Code) EXISTING BLDG STORI[O SIGNATURE. Lic or Reg No - Date PRESENT out OF BUILDING FINAL APPROVAL Z la 0 HOME OWNER-BUILDER DECLARATION NO OF EXISrING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 70315 Business and Professions Code) NO PARKING I I. as owner of the property will do the work and the BPACEBPROVIDED I structure is not intended or offered for sale(Section 7044, PROPOSED USE OF WILOING Business and Professions Code) i 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. 3097,Civ C) PROPOSED MAX OCG Lender's Name r9wr _ TiL No Lender s Address 1 Reae I I certify that I have read this application and state that the MU APW6*1 A-4 UAIA; 0444 above information is correct I agree to comply with aB County MIRMrr FEE ordinances and State laws relating to building construction and ^- hereby authorize representatives of this County to enter upon ISSUANCE vee the above-mentioned property for inspection purposes - _ ,,.y TOTAL FEE g ! 6�'f0-� SEE REVERSE FOR EXPLANATORY LANGUAGE neiure of Permiaee Date