HomeMy Public PortalAbout5608 ROSEMEAD BLVD_Miscellaneous__ NORkI RS (OAIPLNSAIION UICLARATION 76 8]5CE 875 111 841 MISCELLANEOUS APPLICATION
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I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
mnve or a Lertlficate of Workers'(ompensatwn Insurance or
9"trifled Lop) thereof(SeL 3800,Lab C)
Policy No in BUILOIna p
(oro P Y FOR APPLICANT TO FILL IN
FICerutied LOP) Is hereby furnished // I //��� I n
XX AOow ca.J~6� kAV lQ LOCALITY
❑ Certified cops N filed with the county budding inspection LOCALITT NEAREST
department XX CROSS ST
Dite Apphcmt NEAREST DISTRICT cFUP TTra P eaaaD By
Cwos. ST O conar
(I R I11 I(All Of EXEMPI ION I ROM WORKERS LEGAL O
(O\IPI NSAIION INSURANCL oeaeRIPTION Loi No I.L.C. mel I p w�� .icor[ Mwiow a¢conO Lout
NO OF [LDaa
(This section need not be completed of the work involved TRACT NOW ON LOT USE ZONE SPEnwL co nDMIONS
by (he permit Is for one hundred dollars ($100) or IM) wE or }
SIZE OF LOT EXr.TING BLDG J
Lerhfy that in the performance of the work for which this
Permit n nsmed, I shill not employ any person ill any mai of building
a, Is to besonhc slhltt t to the Workers (ompensatnon f asv% OCCUPANCY GROUP2 ra
C7
wOOwa.6 'FI �/ U
Dile _ — Apphum _ o rl ISI
NO I1(I 10 APPLI(ANI If doer making this Certificate of CIT, ,t�q No OCCUPANT LOAD y
I semphon, jou should become subject to the Workers APPLICATION FOR EXIT HARDWARE
(ompenc hou ptovnsions of the Labor Code you must forth-
with Lomply %illi such prosnsinn% or this permit shall be TRAILER us¢ ❑ GEOLOGY INSPECTION 13 No Spec Knowl El
deenred rc%okeJ
1 R I NSI U(ON I RA( TORS DECLARATION oeeurwwcy INSPECTION ❑ Panto Devices
1 henh) affirm that I am licensed under provnsromof Chap et SAFETY PERMIT (LIST ITEM. BELOW)
9 (Cowmen Ing with Section 7000) of Division 3 of the Bust NO Or EXIT.
necLand Professions(ode and my Incense u m full force arl*x Name of business waG D
PAww Bra PROVIDED
{ 1 T .Pw ea.
I ILL nse Number 1 nc (lass1�E D 11011
— LIMITED TIME USE
(onir Klor Pale OATS ow AT.
I im exempt from the hcensmg requirements as I am a PwoM
licensed ltchnleal or a registered professional engnmer SIZE or No ow INSPNCTuwe
acting In my professional Lapi(rt) (Section 7051 Bis EXISTING BLDG crow l¢. NIDI FF °
mess and Professions(ode)
PRESENT USE or BUILDING FINAL APPROVAL
1 he or Reg Na Date N ( i
II(IAII OWNI R Bt 111 DI R UI CLA RA TION TIO OP EXISTING BUILDINGS " (,( Y 3`17 1 PM '/7 • '
oN LOT w.. USE ✓ i r
I herebv iffnm that 1 am exempt from the Contractors
Litems I aw for the follow mg re won (Semon 7031 5 Bus IiV��V
ness and Ptoles%none(ode) NO PARKING
1, as owner of the property will do the work and tie .PACES PROVIDED
structure Is not intended or offered for sale (Sechen
7044 Business and Professions(Ede)
(ONSI RUCI ION LENDING AGENCY PROPOSED USE or BUILDING
I hereto affirm that there n a constructron lending agen y
for the Performance of the work for whish this permit rs
issued(Sec 3097 (tv ( )
I ender s Nime _
PROPOSED MA*-Bee
1 ender s Address_
I ceridv Uwt 1 lose rand this IpphL lion roil state that lhP PERMIT TEE
25.00
abco,emfurmltnonrccorrco l hgrectOLomPI) wnlhall(ounty ISSUANCE FEE
ordinances and State lass% relating to budding construction,
and hereby authorve reprew Ialives of this County to enter TOTAL FEE 25.00
upon thea oe mentioned Pert) for
((m—sP ton purPp sex i SEC REVERSE I'OR EXPLANATORY LANGUAGE
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