HomeMy Public PortalAbout5439 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) M I SC E L LA N'iO U S APPLICATION
CE 875
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insur€;•or a certificate of Workers'Compensation Insurance,or
a cert:�ied copy thereof(Sec. 3800,Lab.C.).
Policy*o. Company FOR APPLICANT TO FI LL IN BUILDING
ADDR ES
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FICertified copy is hereby furnished. ILDING IsAk-
ADDRESSLOCALITY
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❑ Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DI:TR IC NO. G UP TYPE CESSED BY
CROSS ST. �{� CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a
COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDG:.
(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
slzE of Lor EXISTING BLDG.
I certify that in the performance of the work for which this �
C:)
permit is issued, I shall not employ any person in any manner OWNER
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so as to become subject to the Workers' Compensation Laws. MAIL � CCUPANCY GROUP �+ a
ADDRES ,p t3
Date Applicant "Clh(1 ICA W
L.
NOTICE TO APPLICANT: If, after making this Certificate of CITY TNO. OCCUPANT LOAD
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 UI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION-[] No Spec. Knowl. ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION EJ Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] ' 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 SPACES REQ'D PROVIDED
�j.
License Number Lic. Classes 11 LIMITED TIME USE
Contractor Date r c> 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 YGNATURE
iness and Professions Code). FINAL APPROVAL ,�
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 60 ///��t 4� _mm
ON LOT AND USE
y,�/ 4/. _!°moi y )'•o; �y'0.y 4ii
I hereby affirm that I am exempt from the Contractor's V/1I1I
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
0 I, as owner of the property, will do the work and the SPACES PROVIDED
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.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the bove-mentioned property for inspection urposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ature of Permit,-
ermit D to