HomeMy Public PortalAbout5725 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION,DECLARATION CE 875(11-84) M ISCELLANEOU! APPLICATION
I hAreby affirm that I have a certificate: ti coInsur to" self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers;Compensation Insurance,or ,
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
Certified copy is hereby furnished. , BUILDIN6 ADORLOCALITY
ES
Certified copy is filed with the county building inspectionOCALIT I NEAREST
department. 44 CROSS ST.
Date Applicant NEAREST DISTR,CT;NQ. G -Up ITYPE '
P CESS ED BY
CROSS ST. S IT CONST..e
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT 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.
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 OWNER
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
ADDRESS � r V
Date D
Applicant La
NOTICE TO APPLICANT: If,after making this Certificate of CI rY TE _� OCCUPANT LOAD La
Exemption, you should become] subject to the Workers' ig
Compensation provisions of the Labor Code,you must forth- APPLICATIO EXIT HARDWARE: _
with comply with such provisions oI this •permit shall be TRAILER USE GEOLOGY INSPECTIONElNo Spec. Knowl.
❑
deemed-revoked.
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. PARKING
SPACES REQ'D O PROVIDED
l
License Number Lic. Class GT
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO: E-9L SRE
F-1I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer slzE of NO.OF �� INSPECTOR'S
acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL ��S–`�! /7
Lic.or Reg.No. Date
HOMEOWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS f ].5111 ! ��r{;�'er�
ON LOT AND USE l/ I ill e,L:'.
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
I, as owner of the property, will do the work and the ''PACES PROVIDED
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
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name
Lender's Address
PROPOSED MAX. OCC.
gz—F ��
PtEE
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County IE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter EE
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
r �
Signature of Permittee to