HomeMy Public PortalAbout5300 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 8754(2-80) MISCELLANEOUS A P P L I C AT I O N
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 rNEAR
DING
ESS.
❑ Certified copy is hereby furnished. BUILDING ® LITv
ADDRESS
Certified copy is filed with the county building inspection EST
department. LOCALITY
S ST.
Date Applicant AREST RICT NO. GROUP TYPE PROCESSED BY
CROSS ST. - CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK HIGHWgv STATE MAJOR SECOND LOCAL
(CIRCLE) n.
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT ONE SPECIAL CONDITIONS O
by the permit is for.one hundred dollars ($100) or less.)
USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this O
permit is issued, I shall not employ any person in any manner WNER/ F—
so as to become subject to the Workers' Compensation Laws. P01-AIL OCCUPANCY GROUP W
ADDRESS N
Date Applicant Z
TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ..Tv NO. OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION
deemed revoked.
❑ No Spec. Knowl. ❑
❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic D@VICES
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
PARKING
effect' SPACES REO'D E= PROVIDED
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'S'
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE
(ness and Professions Code). RESENT USE OF BUILDING .r FINAL APPROVAL �Q
r
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that- I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section _
7044, Business and Professions Code).
R OPOSED USE OF BUILDING �
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for wJiich this permit is v
issued (Sec. 3097,Civ.C.). \�
Lender's Name PROPOSED MAX. OCC.
Lender's Address PERMIT FEE
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
ordinances and State laws relating to building construction,
hereb authorize representatives his County to enter TOTAL FEE ,
upo e bove- oned propert r i spection purpo es SEE REVERSE FOR EXPLANATORY LANGUAGE,
Signat of P ittee Date