HomeMy Public PortalAbout5410 ROSEMEAD BLVD_Miscellaneous__ •WORKERS'COMPENSATION DECLARATION
76M444.
CE 875 (11-84) MISCELLANEOUS APPLICATION,
I hereby affirm that I,have- a certificate of consent'to self,
insure, or a certificate of Workers'Compensation Iinsurance,,or - _GOU,NTY OF LO'S ANGELES. BUILDING'AND SAFETY DIVISION
'a certified copy thereof(Sec. 3800,Lab:C.).
Policy No. Company -" FOR APPLICANT-TO FILL IN
BUILDING
BU
ILD _ ADDRESS -
Certified'copy is hereby'furnrs}1ed. ING
'
' ..,•'- ADDRESS 'w - LOCALITY
a ^
�
:Certified copYFIs filed with the count buildngurs ection LOCALITY - NEAREST
CROS5 ST
.department.^
Date Applicant' - ' NEAREST - - DISTRICT NO. -GROUP, TYPE _ PROCESSED BY
. - - CROSS ST. .,, �. R /`
�///O - �/ CONST.
'
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
,
COMPENSATION INSURANCE DES i oT Nor BLOCK MAP RIGHWAY
5
OF
NO. I (CIRCLET -
.. - NO:OF BLDGS. -
TATE NI A'JO R SE.CO ND`LOCAL
(This section'need not-be completed if the work, involved TRACT Now ON LOT:- J�E ZONE SPECIAL CONDITIONS'
by the permit is for.,one hundred dollars ($100).or less.) USE of
« .. ., SIZE OF,.LOT ' ..
' ... EXISTING BLDG. •
I certify that m the"performance.,of the work-for which.this o
permit is;,issued, I shall not employ any person in any manner x,
OWNER C-)
so as to become subject to the Workers' Compensation Laws. Al
OCCUPANCY GROUP o
X )� Ie.C
\' ADDRESS /.<w 4",
Date
Applicant-
TES.` 'OCCUPANT LOAD
' NOTICE TO APPLICANT: If;after making this Certificate of�( clrY L No.
N
Exemption, you.should -become, Subject to the Workers' APPLICATION FOR` .. EXIT HARDWARE: `
z
Compensation provisions of.the Labor Code,you must forth-
with comply with such provisions Or this peImlt shall-be TRAILER USE GEOLO GY'INSPE CTION ❑ NO Spec. Know.I, El
deemed-revoked. `• Panic'Devices
LICENSED CONTRACTORS DECLARATION • OCCUPANCY INSPECTION
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 1 1 NO. OF.EXITS
ness and Professions Code, and my license is in full force,and
effect. PARKING REQ'D D. PROVIDED
SP,A CES
License Number Lic. Class 7wfI V t'AN AN/J Ek t C, Al C.: ASP,
,
LIMITED TIME USE
Contractor - - Date DATE - - DATE, -
- FROM: - TO. .
D I am exempt from the licensing requirements as I am a
licensed' architect or a`registered-professional 'engineer SIZE OF NO, of INSPEC:TOR's
acting in my professional'capacity (Section 7051,.Bus- EXISTING BLDG.` STORIES SIGNATURE
iness and Professions Code).• �y2� C)/
' PRESENT USE OF BUILDING
(� FINAL APPROVAL
Lic.or Reg.No. " Date
HOME OWNER-BUILDER DECLARATION ' NO. OF EXISTING BUILDINGS. FEE
. -
ON LOT AND USE -
I hereby affirm 'that'I. am exempt from'' the Contractors '
0 °q �
License Law for the followin •reason (Section 7031.5, Bus `
ness and Professions Code): g Ivo. PAe1cwG - �I `/' �- 13t7i +J0 1 9/1/99
' SPACES PROVIDED ' • ' I -
,I, as owner "of the property, will do the work and the c7t� PM' alf0
structure is not intended or, offered for sale (Section A
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
1 hereby performance that them
ethes a construction lending agency : AV1Aj�l 1 f/ V��ii"VAIZ
p which this permit is
issued,(Sec. 3091,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 Count
g py y. ISSUANCE FEE
ordinances and State'laws relating to building construction,
•and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned.property for inspection purposes. •'
w SEE REVERSE FOR EXPLANATORY LANGUAGE'
Signature of Permittee Date