HomeMy Public PortalAbout5585 ROSEMEAD BLVD_Miscellaneous__ ' WORKERS'COMPENSAnON DECLARATION 788444- --'
CE 876(11-94) MISCELLANEOUS APPLICATION �t
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• , 1 hereby affirm that I have a certificate of convent to ,or — -COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION U
piwrc, or a certificate of Wotkai Compeasatson Insurance,or
a certified copy thereof(See 3800,lab C) i
Policy No Company FOR APPLICANT TO FILL IN
t
wnow[• /,
Certified copy is hereby furnished XX ADORKSS 5585 1q. Rosemad Blvd. LOCALITY
Certified copy is f led with the County buBding hatpetinon LOCALITY NEAREST
department 7(:7GTewle City CROSS ST
Date Applicant NEARKSr arRleT no GwouP rYPK EeSEo eY
CROSS ST CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 0
COMPENSATION INSURANCE DESCRIPTION LOT No BLocK YAP AAAA.
xo or si.DGa (clwc till STATE MAJOR eKconD LOCAL
x
(Thu section need not 60 Completed J the work mdnov
ved rwwcr ow ON LOT USE zoxE [r[CIwL CONO RIONe
by the permit Is for one hundred dollars ($I00) or less.) _ uBE or
1 certify that in the performance of the work for which thisSI K or Lor [Kunwo BLDG C
permit is issued, I shall not employ any person in my manneikX owNKR of buildin ' Inc. `
So, as to become subject to the Workers' Compensation 'caws NAIL J' OCCUPANCY GROUP ® C
Date Applicant Aoowu• Cullerton Drive
NOTICE TO APPLICANT If, after making this Certificate of CITY Franklin Park NoL (708)955-8300 OCCUPANT LOAD
Exemption, you should become subject to the Workeri
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shag be TRAILER OSEGEOLOGY INSPECTION ❑
deemed revoked ❑ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter
SAFETY PERMIT ❑ (LIST RKNE BELOW)
9 (commencing with Section 7000)of Division 3 of the Bur- NO or EXIT*
nen and Professions Code,and my license is in fuB force art*x Nameof business PP RKINa
effect
Srweu Rea o PwoElp[p
License Number Lic Class Sav-On DrUCI # 3616
LIMITED TIME USE
COntrac[o! Date •coo.. DATE ( Itlll=;Ff I1 _
1 am exempt from the licensing requirements as 1 am a - - -
licensed architect or a registered professional engineer SIZE or No or INnKCTow R
acting in my professional capacity (Section 7051, Sus- EXISTING BLDG STORIES • "URK =
mess and Professions Cade) YINAL APPROVAL q
Lic or Reg No Date
PRESENT USE or BUILDING _ O�
HOME OWNER-BUILDER DECLARATION no or [Ximws rU u.DinGS
ox LOT AND us[ \
1 hereby affmn that 1 am exempt from the Contractor's
• License Law for the following reason (Section 7031 5, Buss,
Mss and Professions Code) NO PARKING
I, es owner of the property, willdo the work and the SPACES PROVIDED
structure a not intended or offered for sale (Section
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE or BUILDING
I hereby affirm that there is a Construction lending agency _
for the performance of the work for which this permit u
issued(Sec 3097,Civ C)
Lender s Name _
PROPOSED MAX Dec
25.110
Lender s Address
I Certify that t have rad this application and state that the FensrlT Fee
above information is correct I agree to Comply with all County ISSUANCE FEE
ordinances and State laws mlati g to building concoction,
and he by authorize representatives of this County to enter TOTALF99 25-00
upo t e above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Y-26i XX-a--9 -
ignature of Permittee Date