HomeMy Public PortalAbout5721 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPE>vSATIONI DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or
a certifiedgp�,hereQf(Sec.3800,Lab. ✓�
Poli-&y A- W wUi Company 1IUS,�o. FOR APPLICANT TO FILL IN ADUILDINGDRESS v /� ���"�r� MS ���
FJn3
❑ Certified copy is hereby furnished. BUILDING 17z1 RCSf _A1) LOCALITY PLP 61?4/
ADDRESS
FICertified copy is filed with the county building inspection LOCALITY �rrr��,7 /�p�t/ NEAREST 1I� /� ��rr
department. l � lr� VY,L 7 CROSS ST. k4d -MMAIN AL.
Date Applicant NEAREST / �p �()/1�/]P {1 . DISTRICT NO. GROUP TYPE CESSED BY
CROSS ST. /' V•V IlV Y/ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCI..)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACY NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. a a
I certify that in the performance of the work for which this o
permit is issued,1 shall not employ any person in any manner OWNER `-
so as to become subject to the Workers' Compensation Laws. MAIL 1�(� OCCUPANCY GROUP o
ADDRESS• �� �f1 )/Aln/"v�
Date Applicant TEL ul
NOTICE TO APPLICANT: If,after making this Certificate of CITY ` No. ()(Fp OCCUPANT LOAD 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 oI 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) 1
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS �i FEE
ness and Professions Code,and my license is in full force and / S
�iTT PARKING
effect. REq'D O PROVIDED
SPACES
License Number Lic. Class t��rt T�'i� ° ? 1121/93
Contractor
LIMITED TIME � _
Contractor Date DAT. OAT. 1°oft
ElI am exempt from the licensing requirements as I am a FROM: TO:
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). g /
PRESENT USE OF BUILDING y/�y 0�J/t/()�/i7V�%/4"/M FINAL APPROVAL �_IZ
Lic.or Reg.No. Date .
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS I ^
/y
I hereby affirm that I am exempt from the Contractor's ON LOT AND USE /VI ' Ad�I
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDINGx � l�G'!lRNy'
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.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address _ O
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 ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL. FEEQQ
upon above-men 'one d property for inspection purposes.
C/ trJ 13 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of ittee Date