HomeMy Public PortalAbout5603 ROSEMEAD BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION �
CE875 l�801 MISCELLANEOUS APPLICATION {�
CE 875 �f
I hereby affirm that 1 hase a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C )
Policy No Com an j
P S FOR APPLICANT TO FILL IN BUILDING
AOOR¢se
Certified cops B hereby furnished BUILDINGLOCALITY
/ (
r-1Certified
Certified copy B filed with the county budding inspection L NEAR ser
department LOCALITY CROSS ST
Date Applicant NEAREST {�V C L• »/ ourrtlOr No GROUPe R c IIseo BY
L CR0a9 9T Q lI///IS Q/ — CO..T
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL �J
COMPENSATION INSURANCE Deet RIPT'On LOT rvo BLOC- M.vP AGR Lam'
STATE wit rPwJOR secoNo Lout a
00
ofoN Gs
(This section need not be completed If the work Involved TRACT nnow BLDLOT USE ZONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars ($100) or less) U
use or
SIIE OF LOT E%,,TING BLDG - cc
1 certify that In the performance of the work for which this yO
permit is Issued I shall not employ anv person In any manner L OwNER �+ G S. (�/,B �fC� I—
so as to become subject to the Workers CompLnsation Laus OCCUPANCY GROUP �� L)
I
L MAL 99aPf ,Co G'i�7i q rd lv� W
wo L LU
Dale Applicant �j Z
TE
NOTICE TO APPLICANT If after making this Certificate of t� CITY / (('��DO b NoL OCCUPANT LOAD r U
Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you must forth L� p
with comply With such provisions or this permit shall he TRAILER U,E El GEOLOGY INSPECTION I] No Spec Knowl ❑
deemed revoked
LICENSED CONTRACTORS DFCLARATION occuPwncr mePernoPanic D¢VICeS
R
1 hereby affirm that 1 am licensed under provisions of Chapter I SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000)of Division 3 of the Busi rvo or EXITS
ness and Professions Code and my license Is In full force and
of f ' PARKING ROOD PROVIO ED
PAC/ :ARI es
License Number Lm Class— !
tl LIMITED TIME USE
Contractor Date DATE GATE
I am exempt from the hcenvng requirements as I am a
licensed architect or a registered professional engineer size OF No of INSPECTOR s
acting In my professional capacity (Section 705) Bus EX99TING BLDG sroRl as SIGNATURE
(ness and Professions Code)
FHaHNT USE OF BUILDING FINAL APPROVAL �./�A/ C•�f1�
Lic or Reg No Date I
Gob S�'�i/e Alj;-4
HOME OWNER BUILDER DECLARATION ON LO
No cr AnNoD USE
BUILDINGS
NE
I hereby affirm that i am exempt from the Contractors
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) NO PARKING
,PACES PROv,DEo i
I as owner of the property will do the work and the � �•6 93.9 A
structure Is not Intended or offered for sale (Section
7044 Businessand Aofessmns Code) # • • •O • 88
POSHD USE OP BUILDING +
CONSTRUCTION LENDING AGLNCY
1 hereby affirm that there is a construction lending agencs
for the performance of the work for which this permit Is I Q 1 8'—'8 2
issued(Sec 3097 Civ C)
Lender s Name ( PROPOSED MAX Dec
Lender's Address PERMIT FEE
1 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 building construction TOTAL FEE �LS OQ
and hereby authorize representatives of this County to enter
upon the above mentioned crty for Inspection purposes SEE REVLRSE FOR LXPLANATORY LANGUAGE
SiStore of Perrnittee Date