HomeMy Public PortalAbout5709 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 2000 3DPW12/90 MISCELLANEOUS APPLICATION
I hereby'affirm that I have a certificate of consent to self COUNTY OF LOS'•ANGELES BUILDING AND SAFETY DIVISION _
i =insure,or a certificatd of.Wdrkers'Compensation Insurance,or _ 4. ;
1 a certified copy hereof(Sed. 3800, Lab.C.).
(� Policy No.. ompany rn,& r!R51a w/o FOR APPLICANT TO FILL IN BUILDING
' = BUILDING ADDRESS ADDRESS
Certified copy.is hereby.,furnished. ALIIb LOCAUTY
Certified copy is filed with t unty b 'Iding inspection CITY ZInPP --
' I department. �� 7r t.-R NEARECROSSST. LdfgR.
Date `= ' _Applicant SIZE OF LOT NO.OF BLOGS.NOW ON LOT DIS_TRICT NO. GROUP TYPE PROCESSED BY Q
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO. CONST. C
1 I COMPENSATION INSURANCE MAP HIGHWAY 9-
I I
NO. _ (CIRCLE) STATE MAJOR SECOND LOCAL..
(This section [teed not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL
i by the permit is for one hundred dollars ($/anyqnner
) USE ZONE SPECIAL CONDITIONS
I j11 or er TEL NO.
I.certify that in the performance.of the work s
permit is issued. I shall not employ any person ia
so as to become subject to the Workers' Comp . A RES O OCCUPANCY GROUP Cr
( 1 Date Applicant . Cz-1 -
IT
NOTICE TO APPLICANT: If. after makin this Certificate �h ' oZ��� OCCUPANT LOAD
of Exemption. you should become subje to the Workers' APPLICATION FOR
Compensation provisions of the I:.atior Co you must forthwith EXIT HARDWARE:
( comply with such provisions or'this p mit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑
revoked.
' ❑
'
LICENSED CONTRS DECLARATION OCCUPANCY INSPECTION i Panic Devices
ACT
I hereby affirm thatI am lice d under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW)
t I 9(commencing with Section 7 )of Division 3 of the Business Name o us ess NO.OF EXITS
and Professions Code,and license is in full force and effect.
License Number Lic.Class PARKING• REQ'D D PROVIDED D
t SPACES
I
( I i Contractor--z Date LIMITED TIME USE
i ❑ I am exe 't from the licensing requirements as I am a
DATE DATE
1
license architect or a registered professional engineer FROM: TO:
actin n my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S
(`- I and rOfeSSIORs COde). EXISTING BLDG. STORIES SIGNATURE,
Lic or Reg.No. Date PRESENT USE OF BUILDING FINAL APPROVAL
' HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS 1�Y
I
ON LOT AND USE
I hereby affirm that I am exempt from the Contracto ' License
Law for the following reason (Section 7031.5, siness and
I I Professions Code): NO.PARKING
SPACES PROVIDED
❑ I, as owner of the property. will do a work and the '
structure is not intended or offered f sale(Section 7044, PROPOSED USE OF BUILDING
Business ani Professions Code).
CONSU RUG'TION LE NG AGENCY
iI hereby affirm that there is a struction lending agency for
the performance of the wor for which this permit is issued
( I (Sec 3097,Civ.C.). PROPOSED MAX.OCG
Lender's Name_ APPLICANT(PMNT) TEL NO.
Lender's Address ADDR ss
( j I certify that Lave read this application and state that the
above info tion is correct. I agree to comply with all County PERMIT FEE
ordinanceand State laws relating to building construction,and
hereby thorize representatives.of this County to enter upon ISSUANCE FEE
the ove-mentioned property for inspection purposes. - - ••
TOTAL FEE.-
3 SEE REVERSE FOR EXPLANATORY LANGUAGE
Ignatu a of Permittee oDate