HomeMy Public PortalAbout5701 ROSEMEAD BLVD_Miscellaneous__ WORKERS"COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified c py t eleof(Sec.3800,Lab.C. ._`
Policy No� ��� Company -GQ� � S /f1�%HiQ FOR APPLICANT TO FI LL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING 7e �1~0
ADDRESS
4EF
filed with the county building inspection LOCALITY ./�� y �^yNEAREST
CROSS ST.
pplicant G%91101f?s s�6Awlkxf NEAREST ��� Tj� �� DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST. /fI CONS EXEMPTION FROM WORKERS' LEGAL 'D� v If
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COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NO. OF NO. (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT NOW ON LOT S. USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. a
I certify that in the performance of the work for which this o
permit is issued,I shall not employ any person in any manner O W N E R QA 13 1.111— 1AI a s'
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUPa OZ
Date Applicant ADDRESS �Q j :]j�%� � v
pp TEL. 2/v 3� OCCUPANT LOAD W
NOTICE TO APPLICANT: If, after making this Certificate of CITY No. / 75/7 z
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. U�//7C+�,J PARKING REq'D PROVIDED
SPACES
License Number Lie. Class S G�Iv��S
0_IMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a PROM? TOI
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code).
Lie.or Reg.No. Date PRESENT USE OF BUILDINGx -'� FINAL APPROVAL 112--2-1zi
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS V u'11O FEE
ON LOT AND USE A C, 'n-�
I hereby affirm that I am exempt from the Contractor's ryU /
License Law for the following reason (Section 7031.5, Busi- 1�i3' lQl )�'^—(=r)001 11/ 4I$
ness and Professions Code): NO.PARKING
❑ I, as owner of the property, will do the work and the SPACES PROVIDED 6339 1 PM 4:50
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency �®aelS�
for the performance of the work for Which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE aJU f
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances a laws relating to building construction,
and hereb a e r presentatives of this County to enter TOTAL FEE R51-;06F
upon t ti ed property for inspection pu ose
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dat