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Home My Public Portal About6515-6517 ROSEMEAD BLVD_Building__ WORKERS COMPENSATION DECLARATION 76M444 CE 876 (280) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to sell COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Iphure or a certificate of Workers'Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) C Policy No Company FOR APPLICANT TO FILL IN woowee� J "" IDCertified copy Is hereby furnished UILDI NO 5�5 �'� p Locwurr ❑ AODDI QS P% 1 Certified copy Is filed with the county budding Inspection New RES department oeALlrr C41y CROSS .r eel Date ApplicantwReaT DISTRICT No OwouR rrre rwoc¢ea¢D er CROaB 8T &j7 CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK wP.C.W. } !� neP" O (.1ACL. STATE MAJOR SECOND LOCAL a (This Section need not be completed if the work involved no DV HLDOE UEe ZONE EP CIAL CONDITION. U P rwwcr Now oN LOT by the permit IS for one hundred dollars ($I00) or less) USE OF SIZE OF LOT ¢x IST.NO BLOB cc 1 certify that In the performance of the work for whichthis Q permit Is Issued, I shall not employ any person In any manner W is) F so as to become subject to the Workers Compensation Laws ^C�(Y�A � �Af� OCCUPANCY GROUP U ADDR¢BS 6 WC'J� ayRVJ d Dete Applicant ,n NOTICE TO APPLICANT If after making this Certificate of Iry s' IC` NOL h ;I a 53-1�'3 OCCUPANT LOAD ? Exemption you should become subject to the Workers 1 APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code you must forth O with comply with such provisions or this permit shall bA TRAILER USE❑ GEOLOGY INSr¢CTION ❑ deemed revoked ClNo Spec Know ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices 1 h6reby affirm that 1 am hLensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEM. BELOW) NO of exITS 9 (commencing with Section 7000) of Division 3 of the Fast ness and Professions Code and my license is In full force and PARKING effect a .PACES R60 D D PROVIOH. License Number Lic Class LIMITED TIME USE Contractor Date owr. Dwrc ❑ o 1 em exempt from the licensing requirements as I am a Ilcensed architect or a registered professional engineer SIZE OF No OF INSPHCTOR's acting In my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE mess and Professions Code) tea{ FINAL APPROVAL REGENT USE OF BUILDING �J zfp• Y— LIc or Reg No Date Eyiz 1v J wg t Km HOMEOWNER BUILDER DECLARATION NO OF ex ISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractors S 4 2 9 5 A License Law for the following reason (Section 7031 5 Bust , ness and Professions Code) NO PARKING o D ePAC ES PROVIDED . . • . U u I as owner of the property will do the work and the structure Is not Intended or offered for sale (Section e e • P . . . 7044 Business and Professions Code) Sf woro.ED USE OF BUILDING 0 9 2 G _8 4 CONSTRUCTION LLNDING AGENCY _ 1 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) Lenders Name PROPOSED MAX OCC Lender s Address PERMIT FEE 1 certify that I have read this application and state that the above Information Is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to budding construction TOTAL FEE and hereby authonve representatives of this County to two upop t ab¢v Ent n pr pe y r Inspect n purposes SEE REVERSE I-OR EXPLANATORY LANGUAGE ✓/ -u -$y SIg Lure of Permittee Date