HomeMy Public PortalAbout5535 ROSEMEAD BLVD_Miscellaneous__ WORhLRS (OMPENSATIONDECLARATION 7610444
I hereby aMISCELLANEOUS APPLICATION {�
• CE 875 111 841 Ll
affirm that i here a Certificate of consent to self OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a Certificate of Worl(tti compensation Compenatron Insurance,or
a certified Copy thereof(Sec 3800,Lab C)
policy No (ompany FOR APPLICANT TO FILL IN BUILDIRo
AD Gwa•S �,:J.7.�
Certified copy is hereby furnished suILD INa
RX LOCALITY
Certified depa„ WPy u Med with the county bnOdhig inspection LOCALITYment XX �pu,G'T R erwioni ii
(Yate Applicant NEAREST T mSTwler No owouP rrPa CauaD BY
CROSS ST �D G eons
CI RTII I(ATE Of EXEMPTION f ROM WORKERS' LEGAL 4
(OMPFNSA TION INSURANCE DasewvTION I-1,10 BLOCK "A" jo.euj ea
OF BLDOa Srara Mwaow saeowo LOCAL
O
(Thsechna
nn neral l be completed if the Rask involved Twwer not ON LOT use aoNaSPeclwL CONDITIONSby the permit n for one hundred dollars ($I00) or less.) U
91111 OF LOT aeunnG BLDG
I certify that in the performance of the work for which this n
permit n issued, I shall not employ any person In any mimw3LX o--- of building e,&
111 ss hI his nn¢ Or)gert to the w'orken (ompenahon LawsPo / OCCUPANCY GROUP 01-
Mwll 17)
aoowsss •-
Ihte— Applicant — p w
NO fIC1 I O APPLI(ANI If after making thn Certificate of CIT' 7bri� fl, 1 Roc `,3�- 36� OCCUPANT LOAD
1 Tempthon, )ou should become subject to the Workers APPLICATION FOR EXIT HARDWARE
(ompenauon proviaons of the Labor Code you must forth ❑
with comply with such provisions or thn permit scall be
defined rewired rwwlLEw USE ❑ awwGY INSPECTION ❑ NO Spec KrroWl
1 ICI NSF U(ON I RAC I ORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
1 hereb) affirm that I am licensed under provhDonsof Chapter SAFETY PERMIT ❑ (LIST ITEMS BKLOB)
9 (matmennng with Section 7000)of Division 3 of the Busy NO OF EXITS
Neu and Profesaom(ode and my hcenw is in full force an
effect Name pf business PAwKlno
SPACES Oman Pworrolo
I rams Numhcr Lic (lass ��"'� Ch�J
LIMITED TIME USE
(OntriLtor _ _ Pate ewra Gwra
0 1 am exempt from the licensing requirements as 1 am a •ROMA re.
licensed architect Or a registered professional engineer six orNo o. INSPECTOR S
acting in my professional Capacity (Section 7051 Bus- EXISTING BLDG STowlu aro wruwa
mess and Professions(ode) FINAL APPROVAL �Q -
I is or Reg NO _ _ pate PRasanr use OF BUILDING _
IIOMI OWNER RIIILOFR DECLARATION No OF aKurlwo BUILDINGS
ON LOT a"D sea
I hereby affirm that I am exempt from the ctoi s IOC 61_
I icenw s•mm
law for the foliog um (Section 7031031 5 5 Buri- VV
near and Professmns Code) NO PARKING
1, as owner of the property, ai8 do the work and the SPACES PROVIDED
structure is not intended or offered for ale (Section
7044 9usmess and PTofmions(ode)
(ONS]RUCI ION LENDING AGENCY PROPOSED Use OF BUILDING
1 Ihereb) affmn that there n a construction lending agerry
for the peifortrana of the work for which this permit b
rimed(Sec 3097 (tv ( )
1 ender s Nome
PROPOSED MAR-Dee
ender s Address___ _ ____
PERMIT ICE
I artily that I brae read ihh< apphcinon and •title that the
• Ibose mfOlmation Is CorrClt 1Free to compl) with all County ISSUANCE FEE
ordinances and State law cL7uing to budding construction,
andher art ory
rue rep sentates of this County to enter TOTAL Fee 25.001
i upo one proper() for Inspection pulp'
SEC REVERSE 1 OR EXPLANATORY LANGUAGE
XX XX Lj