HomeMy Public PortalAbout5658 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION
CE 87,ri 111.841 �
r insure.
o affirm that I have a certificate of consent to self COUNTY OF LOS .ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance.6r I '
a certified copy thereof ISec.3800.Lab.C.). — _
Policy No. Company FOR APPLICANT TO FILL IN nooRess :�'� j.,��
❑ Certified copy is hereby furnished. I ILDING
p. AD DR ESS�� LOCALITY
I Certified copy is tiled with the count. building inspection LOCALITY NEAREST C•
department. Temple City Cs ST.
Date .-Applicant NEAREST DISTRICT NO. GRq UP TYPE ESSEO BY
• CROSS ST. (�v 1 ` f !J CON
I CERTIFICATE OF EXEMPTION FROM'.CORKERS' LEGAL U �/r/)'
COMPENSATION INSURANCE � DESCRIPTION LOT NO. BLOCK I.A� HIGHWAY
lCIRCLE) STATE MAJOR SECOND LOCAL
1 NO. OF BLDGS.
(This section need not be completed if the work Involved -RACT NOW ON LOT USE TONE SPECIAL CONDITIONS
by the permit is for one hundred dollars 6100) or less.) usE OF 1
512E OF LOT EXISTING BLDG.
I I certify that in the performance of -lie'cork for-v hich this
permit is issued. I shall not employ any oe.son :n any manner OWNER ,L eeeoce e,, i
so as to become subiect to the Corkers' Canipensation Lags. NAIL , Jy�- �j/� OCCUPANCY GROUP I -
I Dale _ Applicant
- ADDRESS �>✓ CiG -yt✓ /� ,'t!,
NOTICE TU ,APPLICANT: If, aitcr makin_ :his Certifiearc of $I CITY � E OCCUPAN—LOAD
Exemption, you ihould become stibiect -o the Workers' OF AP°LICA�IC I F .X ITH.ARC!Il.APE
Compensation provisions of:he Labor Cade. %.ou must forth- vv
I with comply with itich DIovisions or .his 7ermit shall be -RAILER USE C] K
GEOLOGY INSPECTION _ No Spec. nowl. ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$$ Panic Devices 11
I hereby affirm that 1 am licensed under previsions of Chapter SAFETY PERMITI^_t (LIST ITEMS BELOW)
9 (commencing with Section -000) of Division 3 of the Busi- NO. OF EXITS
ness and P-ofessions Code. and my license is in fall force and
effect. PARKINGj
' SPACES REO.O I I PROVIDED O
Lic
b
N
License Number . Class 1—�
o ° � �� LIMITED TIME USE
LL
w Contractor Date DATE DATE
W
z L am exempt from the licensing requirements as l am .I FvoMo TO:
❑
m 1 licensed architect or a registered professional engineer SIZE OF ND. OF INSPECTOR'S
o -t)_ EXISTING BLDG. STORIES SI NATURE
z actin_ in :n}• professional :ap:l::it.: S�:tiott �1. Btli-
°m iness and Professions Code l' FINAL A PP R O V A L
U PRESENT USE OF BUILDING Q
Lic.or Rea. No. Date �l �,q _
fip�•lE Ot�'NI-R-IiUILUER DE(:LA1t.ATIUN NO. OF EXISTING BUILDINGS /�V� •
E "40604
ON LOT AND USE 1 V
I hereby affirm that I am exempt from the Contractors ) I�
1 License Lav for the following reason ISection 7031.5. Busi-
ness and Professions Code): - NO. PARKING Il 1yV
0 I, as owner of the property. will do the work and the SPACES PROVIDED �n
structure is not intended or offered for sale ISection r
1
7044.Business and Professions Code).
AGENCY PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENC
I hereby affirm that there is a construction lending agency Z114414re4'7-7 0,4/
I for the performance of the work for which this permit is
issued(Sec. 3097,civ.C.). toL t �
Lender's Name
PROPOSED MAX. OCC.
Lender's:Address
I I certify that I have read this application and Mate that the PERMIT FEE 25.00
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 25.00
1 ) upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
� Signature of Permittee Date
1