HomeMy Public PortalAbout5423 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875(11-84) MISCELLANEOUS APPLICATION
CE 875
I n sure, o affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING n
ADDRESS { 11 / LOCALITY
0 Certified copy is filed with the county building inspection OCALITY `--�— NEAREST ;,
department. I '�ty� i Cl �'\ CROSS ST. `�; VJ
Date Applicant MEAREST 1 DISTRICT N'O/// G{�OU� TYPE / i PROCESSED BY
CROSS ST. 11 L ��/I�( / CO NSTIV/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v a
COMPENSATION INSURANCE DESCRIPTION LOT I BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SE CO 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 ($100) or less.) USE OF
SIZE of LOT EXISTING BLDG.
I certify that in the performance of the work for which this O
permit is issued, I shall not employ any person in any manner OWNERn e/ — -
so as to become subject to the Workers' Compensation Laws. MAIL , `l ! ` '` 1 I OCCUPANCY GROUP
G3
Date Applicant "' Lam,
NOTICE TO APPLICANT: If, after making this Certificate of CITY I CL- No� OCCUPANT LOAD
l��zj .C^ lG,
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth
with comply with such provisions or this permit shall be TRAILER USE [:] GEOLOGY INSPECTION ❑
deemed revoked. E) No Spec. Know[.
LICENSED CONTRACTORS DECLARATION OCCUPANCY IN SPECTIPanic Devices
O
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. PARKING
SPA CES
REq D D PROVIDED
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
El FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF IN ECTU7E
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES GNATU E
iness and Professions Code). FINAL APPROVAL �(L
' PRESENT USE OF BUILDING 1 //
Lie.or Reg.No. Date G G
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's z$'7 7 b 5.A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO.PARKING # • o • • 88
I as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section O • • • • • • z
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 1\ V�f 27A-87
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 1�
PERMIT FEE
I certify that I have read this application and state that the CR.5✓ 1
above information is correct.I ag to comply with all County ISSUANCE FEE
ordinances and tate laws re ing to building construction,
cou
and hereby u orize repre nt.dtives of this Cou�n.t,y•to"enter TOTAL. FEE r
on the -mention operty for ren pur oses.
114.
TJ _ SEE REVERSE FOR EXPLANATORY LANGUAGE
O �'
o ermittee Date
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