HomeMy Public PortalAbout5724 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affirm that 1 have certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or% certificate of Workers'
Insurance,
Compensation Insurancnc e,or
a ratified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPL CANT TO FILL IN BUILDING
ADDRESS I.,,�
13 Certified copy is hereby furnished. BUILDING
X15DRESS -� LOCALITY
❑
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY CROSS ST.
Date Applicant NEAREST DISTRICT NO. UP TYPE PROC SED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J s //i)'- v
COMPENSATION INSURANCE DESCRIPf ION LOT NO. e74 BLOCK MAPw�D` H,GH WAY
No. rC f/i� (CIRCLE)
STATE MAJOR SECOND LOCAL /a-
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT 2 NOW ON LOT USE ZONE SPECIAL CONDITIONS 0
by the permit is for one hundred dollars ($100) or less.) y U
USE OF
SIZE OF LOT EXISTING BLDG. cc
I certify that in the performance of the work for which this 0
permit is issued, I shall not employ any person in any manner WNER
so as to become subject to the Workers'Compensation Laws. M OCCUPANCY GROUP �,�� 0
LU
DDRESSAnip
Date Applicant - - N
TEL.
NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. OCCUPANT LOAD
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 INSPECTIONEl
deemed revoked. ❑ ❑ No Spec. Knowl. 0
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and Applicant's Name A! ti PARKING.
effect. REq'D E:= I PROVIDED
SPACES 1�.J
License Number Lic.Class -
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a
Phone - a 13 5.2— 5 6 �M 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). NT USE OF BUILDING FINAL APPROVAL
SE
Lic.or Reg.No. Date 1�
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS -� }
ON LOT AND USE C">4. Yl
I hereby affirm that, I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 1"�7 A.
OPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY /` - # • • • • 4 O
I hereby affirm that there is a construction lending agency t 11,44 � a 1 SNK
for the performance of the work for which this permit is • • • • • • •
issued(Sec. 3097,Civ.C.).
Lender's Name PROPOSED MAX. OCC. I 1. 20-80
Lender's Address 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 aut rize re r s tatives of this county to enter TOTAL FEE
upon the abo enti erty for inspection purposes. SEE REVERSE. E R EXPLANATORY LANGUAGE
l
Signature of Per Date