HomeMy Public PortalAbout5705 ROSEMEAD BLVD_Miscellaneous__ WORKERS'(.'UMFh.NWLUN L)L"L,LAMA11Vty 20-0083DPW12/90
I hereby'affirm that I have.a certificate of consent to self -COUNTY OF LOS ANGELES - :' BUILDING AND SAFETY DIVISION
+ .iiflsum or a certificate of.Wdrlters'Compensation Insurance,or I Iw
:a oertffied copy'tt�h6e�reof(Sed. 380
Policy•N0s21)sa;Iy�r'UWtw^Lt4tj'AKtgt.tf. FOR APPLICANT TO FILL IN '
r •�I . r, ,t. gutatNG
0LRES$BUILDING.AD S
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Certified copy.is.hereb3h furnished ,
IACALITY
•. -KCertified copy is filed with the county building inspection Ci lit-
department. iL l g NEAREST.,
ROSS sT., C
! Date %'• �• •Applicant size of L T NO.OF BCOGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY
CERTIFICATE OF•EXEMPTION FROM WORKERS' ��® "�+' CONST. 4
TRACT BLOCK LOT Na.
COMPENSATION INSURANCE MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL..
(This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($1 00) or less.)
i L certify that in the performance,of the work for which this Clumer eLNa. ~
permit is issued'I'shall not employ any person in any manner S W
! so as to become subject to the Workers' Compensation Laws ADDRE0 �+ U OCCUPANCY GROUP co
Date Applicant • PRY i/ �l ztP Q„1A I
NOTICE TO APPLICANT: If after making this Certificate „� $ I OCCUPANT LOAD
of Exemption. you•should become subject to the Workers' APPLICATION FOR
Compensation provisions of thelatior Code,you must forthwith EXIT HARDWARE:
comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑
revoked No Spec.Knows. ❑
OCCUPANCY INSPECTION Panic Devices ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter: SAFETY PERMIT El (UST ITEMS BELOW) - o
9(commencing with Section 7000)of Division 3 of the Business ame a uslness NO. EXITS o
and Professions Code,and my license is in full force and effect. . (�
PARKING REO'D PROVIDED I .
License Number Zia Class LS PARKIN LL�� h��JJ
Contractor Date LIMITED TIME USE
i _ DATE DATE
El I am exempt from the licensing requirements as I am a •• '
licensed•architect or a•registered professional engineerFROM: To:
acting in my professional capacity(Section 7051,Business SIzE OF NO.OF INSPECTOR'S
and Professions Ggde).
EXISTING BLDG. STORIES SIGNATURE.
Lia or.Reg.No. - Date PRESENT USE OF BUILDING ~ FINAL APPROVAL D�
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
I ON LOT AND USE
I hereby affirm that I am'exempt from the Contractors License
Law for the following reason (Section 7031.5, Business and
I Professions Code): NO.PARKING '
i ElI, as owner.of the property, will do the work and the SPACES PROVIDED.
structure is not intended or offered for sale(Section 7044_1 PROPOSED USE OF BUILDING
Business and-Professions Code).
CONSTRUCTION LENDING AGENCY
T hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sea 3047,CIV.Q.. PROPOSED MAX.OCC.
Lender's Name AP CANT nlr� 1, EL N
Lender's Address DR _
I certify that I have read this-application and state that the 8 7— TA-
above information is correct I agree to comply with all County ,PERMIT FEE
ordinances and State laws:relating to building construction,and
hereby authorize representatives.of this County to enter upon ISSUANCE FEE
the above-mentioned property far inspection purposes . _
„•s• TOTAL FEE
#*PteSEE REVERSE FOR EXPLANATORY LANGUAGE
Signal a Permittee