The URL can be used to link to this page

Home My Public Portal About5546 #208 ROSEMEAD BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION z0""IZDPW12/90 MlbL;I:_LLAIVI✓UUD Ht't'LIt,.HI IVIY - I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure or a certificate of Workers Compensation Insurance. or a certified copy thereof (Sec 3800 Lab.C) Policy Na Company FOR APPLICANT TO FILL IN BwLAwa rz. Certified copy Is hereby furnished & 8 — .Y. ADDRESS // �i �E83 C—,07,! j d aL�I .. y,L� LOCALRY Certified copy is filed with the county building Inspection a*Y ZIP department TCzs L C rTy I / NEAREST CROSS BT Date Applicant 512E OF LAT NO OF BLDG Nosy ON LOT DIBTRIC N UP TYPE ssED BY CERTIFICATE OF EXEMPTION FROM WORKERS // 00 d' Jj � cower COMPENSATION INSURANCE TRACT BLOCK LOT NO w Icurc..e� STATE MAJOR SECOND LOCAL (y Is S permit Heed not be completed l the work involvedles&) ASSESSOR MAP BOON PAGE MRCEL USE ZONE YPECIAL CONDITIONS ,by the permu is for one hundred dollars IS 100) or less.l 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 Property so m to become subject to the Workers Compensation Laws. AOD s OCI`..UPANCY GROUP Date Applicant CITY 'NOTICE TO APPLICANT If after making this Certificate OCCUPANT LOAD W Exemption, you should become subject to the Workers APPLICATION FOR EXI r HARDWARE Compensation provisions of the Labor Code you must forthwith comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSMCTioN❑ No Spec Know[ E]revoked LICENSED CONTRACTORS DECLARATION OCCUrANCY INSPECTION El Panic Devices ❑ 1 hereby affirm that I am licensed under provisions of Chapter - SAr PER IT❑ wsr ITEMS BELOW) No 9(commencing with Section 7000)of Division 3 of the Business OWEXITS and Professions Code and my license is In full force and effect MRKa RED D E= PROVIDED License Number Lic Class vwces Contrector Date LIMITED TIME USE ❑ 1 am exempt from the licensing requirements as 1 am a rROM DATE TO DATE licensed architect or a registered professional engineer acting m my professional capacity (Section 7051 Business SIrE or NO or 19MCTOR B i and Professions Code) onTING BLDG IrTOmES frIGNATURE Lic or Reg No Date PFESENT USE or BUA.MNO FINAL Ar PROVAL C/A IJ TJ HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS D I�� O ON LOT AND USE "Ihereby affirm that I em exempt from the Contractor s License Law for the following reason (Section 70315 Business and - I/ Fwfessions Code) I No MRNING ❑ I as owner of the property will do the work and,,th,Lyr SPACESPROVIDEG structure IS not intended cr offered for sale(Section 71199p PRO o Use OF BUILDING Business and Professions Code) V 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 (SCC 3097 CIV C) PROPOSED MAX OCG er s Name APPLICANT(Pb//1 TEL NO Lenders Address ADORESe 1 certify that I have read this application and state that the above information is correct, 1 agree to comply with all County PERMIT FEE Ordinances and State laws relating to budding construction and hereby authorize representatives of this County to enter upon ISSUANCE PEE the above-n entioned p�Operty f inspection ourposas TOTAL FEE 12-Zr I SEE REVERSE FOR EXPLANATORY LANGUAGE to Signature of Permutee