Loading...
HomeMy Public PortalAbout4930 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) M I SC E L LA N E`O l� PLICA T I O N I hereby affirm that I have a certificate of consent to self COUNTY OF,LOS ANGEL S"'' BUILDING AND SAFETY DIVISION insure, ,1:r a certificate of Workers'Compensation Insurance,or 'fl a certified copy thereof(Sec. 3800,Lab.C.)." ' Policy No. Company FOR APPLICANT TO FI LL IN BUILDING • ADDRESS /�•7 LLrI�/'��. Certif d copy is hereby furnished. wUILDIN f�.. OS I LOCALITY DDRESS Certified copy is filed with the county building inspection LOCALITY ) j /`. NEAREST departmeht. (� I "��/ CROSS ST. NEAREST �f �ii DISTRICT NO. GROUP TYPE P ESSED BY Date Applicant CROSS ST. L /SID ;eW ��� _3 CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL fl COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) usE of I certify that in the performance of the work for which this slzE of Lor EXISTING BLDG. b permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP � MAIL `© L ADDRESS 3(?' �♦ � � C3 1 Date Applicant � LO NOTICE TO APPLICANT: If, after making this Certificate of CITY A-&) n� 4911L'Z No. �gt� OCCUPANT LOAD Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. OCCUPANCY INSPECTION 0� Panic Devices El LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- No. OF EXITS ness and Professions Code, and my license is in full force and effect. PARKINGREQ'D D PROVIDED D SPACES License Number Lic. Class LIMITED TIME USE Contractor Date — / DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR•: acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG TORE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING -.�•-_` Lic.or Reg.No. Date _ HOME OWNER-BUILDER DECLARATION No. of EXISTING BUILDINGS ��• ``1`�`"�' _ ON LOT AND USE I hereby affirm that I am exempt from the Contractor's �` 77a,7, _ ,'rt License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING I. 1, as owner of the property, will do the work and the SPACES PROVIDED 34 45 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING lH A NG E 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.). _ _ Lender's Name _- 1 PROPOSED MAX. OCC. ---�;: ...i. A-Il 9,,�'T Lender's Address D I certify that I have read this application and state that the PERMIT FEE above information is correct.1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE ` upo the above-mentioned property for inspection purposes. ? Q3 SEE REVERSE FOR EXPLANATORY LANGUAGE ZZ 1 ,�l'r_Slg>� 1i�o ) �t %r� Da(e e WORKERS'COMPENSATION DECLARATION 'CE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I 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 No. Company FOR APPLICANT TO FILL IN BIfiLDDRESS t ING 93v 1p ©`/ /� AO ❑ Certified copy is hereby furnished. BUILDINGj n P LOCALITY . ADDRESS .�{v, I "40,j /Ipy 0� 3j J, _ ❑ Certified copy is filed with the county building inspection NEAREST .j— j �®� Q department. LOCALITY CROs ;. W Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESS CROSS ST. LOA/ - 'CONST.' CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP HIGHWAY STATE MAJOR SECOND L CAL NO. OF BLOCS. (CIRCLE) d (This section need not be completed if the work involved TRACTNow ON LOT USE ZONE SPECIAL CONDITIONS 0 by the permit is for one hundred dollars ($100) or less.) /t USE OF SIZE OF LOT �O x O fJ EXISTING.BLDG. I certify that in the performance of the work.for which this 0 permit is issued,I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL G N OCCUPANCY GROUP I I W ADDRESS ;�O® CQ 1" (��f�'-� (JY•`f If (L Date Applicant TE - �jC�� VZZ ) NOTICE TO APPLICANT: If, after making this Certificate of CITY UJ%Af fA f Q// NOL 3 / OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I,hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) a 9 (commencing with Section 7000) of Division 3 of the Busl- NO. OF EXITS ness and Professions Code, and my license is in full force and effect. , SPACESG REO'D PROVIDED License-Number Lic.Class — �J LIMITED TIME USE Contractor Date — DATE DATE FROM: TO: ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF �1 INSPECTOR'S acting in my professional'capacity (Section 7051, Bus- EXISTING B}.D G. STORIES Qrvr. s NATURE iness and Professions Code). PRESENT USE FINAL APPROVAL OF BUILDING Cj�� N� Lic,or Reg.No. Date 3/11Z HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE t/tJ a I hereby affirm that, I am exempt from the Contractor's Do e,,j/ /f N -y OCL e e License Law for the following reason (Section 7031.5, Busi- ness and Professions Code NO. PARKING )' SPACES PROVIDED r�,t� CL'[,.1.. �'('$ ❑ 1, as owner of the property, will do the work and the Ge structure is not intended or offered for, sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING /� 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.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE /q L/r I certify that I have read this application and state that the above information is correct. I agree to comply with all County ISSUANCE FEE SD ordinances and State laws relating to building construction, TOTAL FEE �Q and hereby authorize representatives of�thisCmy to enter up� th bove-mentioned pro rty forn purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -,3a Signature of Permittee Date