HomeMy Public PortalAbout5318 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 875
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 BUILDING
�r ADDRESS
Certified copy is hereby furnished. BUILDING LOCALITY
ADDRESS fad
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO. P TYPE PRO ESSED BY
GR
CROSS ST. Pry • d CONST.�'J� /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE I 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
SIZE OF LOT EXISTING BLDG. - d
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner OWNER y
so as to become subject to the Workers' Compensation Laws. L��
p MAIL OCCUPANCY,GROUP.
0
ADDRESS v i3
Date Applicant LU
TEL OCCUPANT LOAD 0-
NOTICE•TO APPLICANT: If, after making this Certificate of CITY a No. Z _ z
Exemption, you should become subject to the Workers' APPL CATION FOR EXIT HARDWARE: _
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USE ❑ GE LOGY INSPECTION ❑ No Spec. Knowl. 0
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
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 Exlrs
ness and Professions Code, and my license is in full force and
effect. PARKING
SPACES REQ'D D PROVIDED D
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE of NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date gg
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGSH FEE
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- CjCI 00 Ij p011 3Sf.15 j 9
ness and Professions Code): NO. PARKING
SPACES PROVIDED
I, as owner of the property, will do the work and the 1v }-I 1 AN 7:51
structure is not.intended or offered-for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
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
Lender's Address
PROPOSED MAX. OCC.
PERMIT FEE �� C
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,
d hereby authorize representatives of this County to enter TOTAL FEE ( _
,on the above-ment' ned property for inspection purposes.
E REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date