HomeMy Public PortalAbout5430 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS 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'Compensation Insurance,or
a certified copy thereof(Sec.3800;Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN- BUILDING 1 n
ADDRESS 11
❑ Certified copy is hereby furnished. ADDREss 5430 id. Rosemead Blvd. LOCALITY
Certified copy is filed with the county building inspection NEAREST
department. 06CALITY Temple City CROSS ST.
Date Applicant EAREST DISTRICT GR UP TYPE PR SSED BY
CROSS ST.:BroadwayCONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL _� O
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
ND. p2D (CIRCLE) STATE MAJOR SECOND OCAL LL
(This section need not be completed if.the work involved NO. of BLOGs. p
l P TRACT NOW ON LOT USE ZONE S CIAL CONDITIONS
by, the permit is for one hundred dollars ($100) or less.)
USE OF
S13E OF LOT EXISTING BLDG.
I certify, that in the performance of the work for which this 0
permit is issued, I shall not employ any person in any manner owivER Mr. Bade Mr. Langley 1-
so
so as to become subject to the Workers' Compensation Laws. VE�)
OCCUPANCY GROUP LU
ES59Q9 S. Santa -Anita _ ._ _
Date Applicant 11�� Z
NOTICE TO APPLICANT: If, after making this Certificate of Arcadia NO.018-574-7354 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 0 GEOLOGY INSPECTION No Spec. Knowl. ❑
deemed revoked. a Panic DeVIC@S ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisioijs 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
effect. - PARKING. REQ'D PROVIDED
SPACCESES
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 INSP FjCTO R'S
acting in my professional capacity (Section 7051, Bus- Exl TING BLDG. STORIES SI ATURE
iness and Professions Code). RFINAL APPROVALESENT USE OF BUILDING Vacant Warehouse � l �
Lic.or Reg.No. Date
NO. OF EXISTING BUILDINGS lU ^/
HOME OWNER-BUILDER DECLARATION
ON LOT AND USE g 1 h
I hereby affirm that I am exempt from the Contractor's
2 a
License Law for the following reason (Section 7031.5, Busi- In
ness and Professions Code): NO. PERKING • • • • • • • z
SPACES PROVIDED •I lI 0(� 4
y O V /I
❑ 1, as owner of the property, will do the work and the I 1
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
OPOSED USE OF.BUILDING
Retai 1- & Wholesale
CONSTRUCTION LENDING AGENCY Sales of Janitorial Supplies Fr
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is Equipment.
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, TOTAL FEE
and hereby au horize representatives of this County to enter o
up e a e-mentione property ec 'for insp `n urp ses. SEE REVERSE FOR EXPLAN ORY LA GUAGE
Signatur' of Permittee Dale