HomeMy Public PortalAbout5533 ROSEMEAD BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION
CE 875 111A41 MISCELLANEOUS APPLICATION {�
CE 878 LJ
I hereby a certificate Insurance,that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certcate of Workers Compensation Insunce,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN woos.o J�r
Certified Copy is hereby furnished 'Y1Lp1NO Jr53 5 Ft 6A U
ADORES• Loewur
Certified copy u filed with the county building inspection Lo ew urr
department TSM I[.6 Cr r 9/786 cwoia.r
Date Applicant NEARUT DIerRlcr N wouP Tr PE CUSSED By
ewo.e ST !�/��A/N//� �o/ -/� CONST
CERT1fICATE OF EXEMPTION FROM WORKERS' LEGAL «!!
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP
OF ELDGI (CI RCLE' arwre Mwiow SECOND LOCAL
(Thu No section need not be completed If the work involved TRACT nor ON LOT Z NE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) useor
JI
1 certify that m the performance of the work for which this SIZE OF LOT a .TING BLDG C- o
permit is issued. I shall not employ any person many manner
OWNER T /7k.e, L.Z
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP -a o
Date Applicant
ADDRESS 3 ,JYeu 114(+IL A6*9µ36q 1_ z W
U
NOTICE TO APPLICANT If, after making this Certificate of CITT NOL OCCUPANT LOAD 0-
Exemption, you should become subject to the Workers'
Compencrtion provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE
with Comply with such provuaons or this permit shall be TRAILER USKGEOLOGY INSPECTION
deemed revoked ❑ ❑ No Spec Krtowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOIN)
9 (Commencing with Section 7000) of Division 3 of the Busr NO or EXIT$
ness and Professions Code,and my license is in full fora and
effect PARKING
tPAeEt RED PROVIDED
License Number Lic Class T_ LIMITED TIME USE
Contractor Date DAIS CAT.
❑ 1 am exempt from the licensing requirements as I am a PRC. T..licensed1
architect or a registered professional engincer SIZE or No Or To' e
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES wE
mess and Professions Code) FINAL APPROVAL 1
Ln: or Reg No Date PRESENT USK or BUILDING I
n G /94
HOME OWNER-BUILDER DECLARATION NO or EXISTING BUILDINGS 14
V� FEE &.5-1
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Busy f QfIQ[I—Q[I[)1 7/iv/94
ness and Professions Code) NO PARKING
1, as owner of the property, will do the work and the SPACES PROVIDED 5109 1 AN 3:217
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,Cw C)
Lender's Name
PROPOSED MAX Dec
Lender's Address
I certify that I have read this apphmtion and sate that the PERMIT FEE
above information is core t I agree to Comply with all County ISSUANCE FEE
ordinances d Sate la relatvig to building Construction, M
and hereb a r¢e r sentatrves of this County to enter TOTAL PEE
upon the v entero property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
✓ 6 .,?-
Signature of Permittee Date