HomeMy Public PortalAbout5505 ROSEMEAD BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION 7eM444 M ISCELLANEOUS APPLICATION
CE 878 111 84)
1 here, affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Iwrance,or
a certified copy thereof(Sec 3800, Lab C)
Policy No Company FOR APPLICANT TO FILL IN DUILoinO
woowE•
Certified Copy is hereby furnished EUUDINa
woaw ESSti ^�- Louur
department CopyCertified u filed with the County budding Inspection coeur. 1--�+r,l GC C x[Aw[er
CROSS ST
Date Applicant NEAR"'
Durww!/ti Aft
rvo o 5 TYPK ceSS ED DY
CERT1fICATE OF EXEMPTION FROM WORKERSLEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO DLOCKYw wxwwY
No (CIRCLE) STAT[ MAJOR •KCOrvD LOCAL
(Thu section need not be completed d the work involvtd TRwcr nNo ovr on or KLDOe Lor use zoxe SP[euL coNmnox•
by the permit Is for one hundred dollars (5100) or less) UeE or
SIZE or Orr ez USING at.DO
1 certify that in the performance of the work for which the o
permit Is issued, I shall not employ any person in any manner oerweR v
so as to become subject to the Workers' Compensation Laws MAIL s O OCCUPANCY GROUP �- o
ADDRESS
Dale Applicant
LU
NOTICE TO APPLICANT If, after making the Certificate of cIT, TEL 17 aLCfa 10Q OCCUPANT LOAD
Exemption, you should become subject to the Workers' VAPPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code,you must forth
with Comply with such pmvmons or this permit shall be ❑ ❑ No Spec Knowl
deemed revoked TRAILER use a[oLoov iNSPKcraoN
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter ur[rY PERMIT ❑ (usr ITEMS Eecov)
9 (Commencing with Section 7000) of Division 3 of the Busy no OF EKiTe
tress and Profemons Code,and my license u in full fora and
effect O 1 S Sw Rea D PRovIDED
SPACES
KQE
License Number Lac Class LIMITED TIME USE
Contractor Dale DATA DAYS
1 am exempt from the lacensag requirements as I am a
PYOY r0
licensed architect or a registered profesaonal engineer SIZE orNo or INSPECTOR'S
acting in my proftsaonal capacity (Section 7051, Bus- EXISTING DODO [Towles [tory TURK
mess and Professions Code) � ., FINAL APPROVAL 23
Lac or Reg No Dale PR KeKNT uee or EuiLDiNO l
HOML OWNER-BUILDER DECLARATION NO or EXISTING autcDanos
f` LD q3 N FEE
ON Lor AND USE
I hereby affirm that I am exempt from the Contractor's py��'j
License Law for the followmg reason (Section 7031 5, Busr
1010100--13001 bin air
ness and ProfessionsCode) NO PARKING property, 0161 1 PM26"
I, as owner of the ro rt will do the work and the SPACES PROVIDED structure Is not inor or offered for We (Section
7044,Business and Professaom Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE or KUILDINO
I hereby affum that there Is a construction lending agency
for the performance of the work for which this permit is
usued(Sec 3097,Cw C)
Lender's Name
PROPOSED MAX OCC
Lender's Address reRMar FEE OV
I certify that 1 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 budding construction,
and hereby authorise representatives of this County to enter TOTAL FEE 5.
u`on t above-mentiog4property for mspecluo� rl purposes
AT 3 SEE REVERSE FOR EXPLANATORY LANGUAGE
Sgnature of Permnice Date