HomeMy Public PortalAbout5546 #102 ROSEMEAD BLVD_Miscellaneous__ j• f e WORKERS COMPENSATION DLCLARATIO♦
oesaDR.neiso MISCELLAN�,oUS APPLICAI uUN �I
so
I hereby affirm that I have a certificate of consent to s if COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
+ Insure.or a certificate of Worlers Compensation Insurance or
a certified copy thereof (Sec 3500 Lab C)
Polity No Company FOR APPLICANT TO FILL IN BUILDING i ✓G fL/��Jj�,c�i
�i BUILDING D ESS r�r p� /f� ADDRESS
f❑J Certified cop) is hereby furnished rJ R0.,M RLVD GTE R2 LOCAurY
Certified cop% is filed x ith the count% building inspecuo 1 CIT
NEAREST 7fCITY C� 00 CRSS sr
Date Applicant SIZE OF LOT NO OF SLOGS NOW ON LOTDI9 T P TYPE P CESSED BY
CERTIFICATE OF Ea EMPTIO\ FROM WORKERS 7N G DONar ��
COMPENSATION INSURANCE TRACT BLOCK LOT NO PAP .wwxAv
(This section need not be completed if the %%orf. Implied "D 6Map STATE MAJOR SECOND LOCAL
P ASSESSOR MAP BOOK PAGE PARCEL _SEZONE SPECIAL CONDITIONS
b% the permit n for one hundred dollars (51001 or less I
1 1 1 ceruf% mat in the rformance a the %%ori for "rich [ u, OWNER �J 'rEL No
Dermn is issued 1 shall not em w% am i Property ��rr✓ ✓
p p,,,on Ir am marner ADDRESS
D e to oecome Applicant
to the \1orAers Comptnwnon L.Ix> 6 R"/EM �W 1D2 OCCUPANCY GROUP
I Date Appllcan[ a- IIVVJJ 1.� ziP
NOTICE TO APPLICANT If atter maAme ties Cero Ir." L OCCUPANT LOAD
of LXemption %ou shoald Decant suolect to he 'Aoi APPLI;ATID\FOR 9 . E)IT -1APDWARE
Comptmauor,prow,ions o`the "nor Coat %oto mu,t fo- h%nJ j
1 comph %%Ith such pro%kion, Or ins perms, >ndn De arI _
e_ te TRAIR LSE_ JEOLOG% 1\s PECTION] No Spec Kno iI LJ
It,oked
LICE\SED CO\TR CTORS DELL .R \TIU\
OCCUOANCI INSPECTION�_ Da9l: DC%1.',es
A
I htr4% 1.1�'�� .hal I JIM rer,e,, 1110-T prJ%"10,1, D ChJjhC "FE-) -ERM T_� _i '1-EMs BE-01 --7
• O Icomm:ncmg% ith Section 70%,()1 u, Dn ni,n -of ,h_ Bu,nes NO OF EX T- j
and Prole,clon,Coat and m% hc• ,e n u lull lorc. aid
ATG REC C --1 PROVIDED
e L¢er»e \,, Dc- _ Ln: Cl-,. __ -ACEs
conracr — D t _— LIMITED TIME USE
DA'E DATE
I ei-i -%empi from the heer,ln_ .am^m.1t, K I an TO
licensed archuset o- I r _I,i:rd r-ol, ionilnEme.` wsPEC-DR s
Jctl,_ - m, pracs,l mal c in l.a IS.c U n -v I Buhr, S ZE OF NO OF s,G TURE
_115TING 8_D] --ORIES
• end ProtesslDnc Cod. ' r��
PRESENT USE Or 9JI_DWG CAt\Z F NAL APDROJAL��-[f-
u: � Re_ \o DJs• I B'
i HOME 0\t \ER-BLiLDFR Dh CLiR ATIO\
NO OF EXISTING SUI_OINCS
ON LOT AND USE
I ncii affirm that I am c%cmp, irom the Contractor s Llcei 1
LTi for [ne folloxing reason (Section 7031 , Business and
1 ' Frolesstens Code) I NO PARKING
LI /O
ElI as of Der of the pmpem xdl do the iorh and the EPAC ES PROV DED
structure is no, intended o offered for sale (Section 7044X PROPOSEOuscO'I'BuILDING V \
Business and Professions Code) 1
i
CONSTRUCTION LENDING AGENC1
I h.mb% affirm that there is a construction lending agent% to,-
the
orthe performance of the xorA for xhich this peril[ i, issued
t (Sec 3097 G% C) I PROPOSED MAX OCC, I,
Lenders Name I APPLICANT,rtN)1 TEL NO
Lende-s Address ADDRESS
1 I cern(% that I ha%e read this application and state that the
above mformanon is correct I agree to comps% xith all Counts PERMIT FEE
oramaaces and State lax ng to budding construcuor and
her b% But in r ntatn of this Count) to enter upon ISSUANCEFEE
i the ove- tionspropert% for inspection purposes
TOTAL FEE
h ISI 7vt" SEE RE\ERSE FOR Ea PLANATORI LANGUAGE
( Signature of Pe nice Date
i