HomeMy Public PortalAbout5632 1/2 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 7610444
CE 875(2-80) MISCELLANE® S APPLICATION
I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'
rs'Compensation Insurance,or _ f
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company i FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is hereby furnished. I ADDBUILDIRESS NG t6 /
LOCAL( Y
2 e
Certified copy is filed with the county building inspection I Le H/. 7 Q (NEAREST
department. LOCALITY G cRoss ST.
Date Applicant I NEAREST r TRICT N OUP TYPE P SSED BY
CROSS ST. CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �•
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. OF LOGS. No. (C
IRCLE)
STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved I TRACT NOW ON LOTUSE ZONE SPECIAL CONDITIONS Q
by the permit is for one hundred dollars ($100) or less.) USE OF b U
SIZE OF LOT EXISTING BLDG. I G
I certify that in the performance of the work for which this I J C
permit is issued, I shall not employ any person in any manner I OWNER 0
so as to become subject to the Workers' Compensation Laws. I MAIL C OCCUPANCY GROUP U
ADDRESS J2,f Rns em e a a
Date ApplicantTE' Vj
NOTICE TO APPLICANT: If, after making this Certificate of CITY ��� NOL OCCUPANT LOAD
Exemption, you should become subject to the Workers' ,
Compensation provisions of the Labor Code, you must forth- APPLIIbATION FOR EXIT HARDWARE:
with comply with Such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION
deemed revoked. ❑ ❑ No Spec. Knowl. ❑�
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E] Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT [� I a
(LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and I .
effect. PARKING REQ'D
SPACES PROVIDED
Lt:ense Number Lic.class.
r. I I LIMITED TIME USE
Contractor Date I DATE DATE
FROM: TO:
I am exempt from the licensing requirements as I am a.
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051., Bus- I EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL S "�
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTION LOT AND USENG BUILDINGS
I hereby affirm that, I am exempt from the Contractor's ;E1 5 8 5 A.
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO.PARKINGSPACES PROVIDED 10 O O O
I, as owner of the property, will do the work and the o o 0 o o 0 0
structure is not intended or offered for sale (Section
7044,Business and Professions Code). PROPOSED USE OF BUILDINGNb 8
CONSTRUCTION LENDING AGENCY i
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name` I PROPOSED MAX. OCC.
Lender's Address PERMIT FEE
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County i ISSUANCE FEE
ordinances and State laws relating to building construction, TOTAL FEE n / II ��
and hereby authorize representatives of this County to enter i ��Q� / /
upon the above-mentioned rope y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
e � I
Signature of Permitt Date