HomeMy Public PortalAbout5230 ROSEMEAD BLVD_Miscellaneous__ WORKERS':COMPENSATION DECLARATION' 44
76M4 '
CE 875 (2-80>.' ;.M-ISCE.L:LA N,:EOl1S 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'Compe*nsation'Insuia'nce,or
a certified-copy'theieof(Sec.,3800,Lab,C.)' `
Polic No. Com an _ Bu1coING
Y, p Y FOR'APPLICANTTO FILLIN_
Certified copy,is hereby,'furnished. UILDING' LOCALITY
ADDRESS •..�
P copy'is filed with the county bulldmg inspection ,. p _ NEA'REST'.
Certified ent. 1 �� e ;cRoss'sT .
LOCALITY TL'/,�
depa l�J`
j.
Date Applicant NEAREST DISTRICT G UP TV PE MSED BY
CROSS ST.: _ CONST,.- /
..r �V V�+V ,
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL'
COMPENSATION INSURANCE DESCRIPTIO N Lor NO., BLOCK Mqp FIGM WAY
., .. .. NO. .i _ (CIRCLE( ..S _O _
.. .n. - - -
TATE MAJOR SECON D'LO_CAL
•NO. OF BLDG'S -
(This section need, not be.-complefed=if the Work -InVO1Ved'- TRACT, NOW ON.LOT USE ZONE 'SP CIAL.CONDITIONS U'
by: the permit is fore-one hundred dollars ($100):or`1ess). sE'oF
SIZE OF LOT. EXISTING BLDG.'
I certify that.in the performance of the work for which this' �n 0
permit is issued, I shall-not employ any person in any manner.:POWNER l�ll�E:; A.00 4�" 11
U'
so as"to become subject to';the Workers' Compensation Laws.' OCCUPANCY GROUP` a
A,i r
S.eN� cb .
. , ADDRESS wh�
.Date .. , - -Apph71 cant :. ` . .
NOTICE TO kPPLIcXNT:.If; after making:this Certificate of r CI rr � `G• Ct 1 rv.� oLO'79 OCCUPANT LOAD
Exemption,; ,you should become subject 'to the Workers' z
Compensation provisions of the Labor Code,'you must forth-. 'APPLICATION F,OR EXIT:HARDWAR.E.
with- comply with such .provisions or,this permit 'shall be TRAILER USE GEOLOGY INSPECTION°
deemed revoked. "
0 (]`,' Spec ❑
v:
OCCUPANCY.INSPECTION I -
No- . Kriowl
LICENSED,CONTRACTORS DECLARATION Pan C DeVIC@S ❑,
I hereby affirm that lam licensed under provisions of Chaptersw FETY PERMIT (LIST ITEMS BELOW) ,
NO. OF EXITS
9 (commen;cing with Section 7000) of Division 3 of.the Busi-...
na; d
ss and Professions Code, anmy license is in full force and PARKINGeffect.. REQ'D
PROVIDED .
_ - .-. SPACES L�J
License Number Lic,."Class
r
LIMITEDTIME USE..
Contractor Date: DATE '.DATE
FRO..': To. -
• ❑ I'am'exempt from the licensing requirements as„I am a' s<
- licensed. architect''Or a"iegistered, professional engineer:; SIZE OF " , - '1iNSPECToix's. - «
NO. OF. -
acting in my professional capacity. (Section 705,1,-BUS EXISTING BLDG. STORIES
`^n ICN
.lness.'and'PrOfeSSl onSCOde'). r , RESENT USE OF BUILDING 1]>Pi� ... FINAL APPROV AL' . .-_.,�f sem.=A
URE.
Lic.or Reg.No. Date: '• _. ,
'EPI,I�
HOME OWNER-BUILDER DECLARATION Ivo:OF
EXISTING,BUILDINGS a'
ON LOT AND USE - -
I hereby affirm thatI am exempt from the Contractors
License Law for.the following reason (Section 7031:5,, Busi- P–,3,0'2.',5 R
NO. PARKING,
ness and Professions-Code). < _ f
SPACES PROVIDED-
I; as"owner of the property, will'do the.work,and the I` # a Fe o D8 8
.structure„is not intended, or offered;for sale (Section or
7044, Business and Professions Code).' _ fol` o o py
.POSED USE OF BUILDING le
CONSTRUCTION LENDING AGENCY_ •=, xZ 2'7,—,8 4
I hereby affirm that there is a construction lending:agency,
for the performance of• the-..work' for which this permit is R '
issued(Sec. 3097,Civ.C.). ;
Lender's Name PROPOSED MAX. OCC:.`''•..
'Lender's ddress V,
. PERMIT FEE i'.. . .. � •. ,
.. 1 .. -
I certtif that I have read 'this application,and state that the
above-i orm ion is correct. I agree to,comply with all County ISSUANCE FEE l�
ordin' es:a Stat)re s.relating to building constructionand Eby thorizre tatives of-this Count :to enter TorA� FEEQupo he5ve-mend roperty'for inspection purp ses. SEE REVERSE FOR EXPLANATORYLANGUAGE'
ignatur of PLKmittee Dafe