HomeMy Public PortalAbout5730 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DFCLARATiON I 76M444
IF CE 875(280) MISCELLANEOUS APPLICATION
I hereby affirm that 1 have certificate of consent to self I COUNTY OF LOS ANGELES 13UILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or ,
a aertified copy thereof(Sec.3800,Lab.l_'.) I 'fl
Policy No. Company I FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. i 13-IMLOING O /J LOCALITY
DDRESS L4
❑ Certified copy is filed with the county building inspection NEAREST
department. LOCALITY G cvoss ST.
Date Applicant NEAREST DISTRICT N$� UP TYPE
1PROr
SSE ABY
CROSS ST. LQs v Q ,r�0 fI r� CONST. /�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL .e /J �/
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAv
No. (CIRCLC) STATE MAJOR SECOND LOCAL
NO. OF SLOGS.
(This section need not be completed if the Work involved TRACT NOW ON LOT USC ZONE I S ECIAL CONDITIONS 0
by the permit is for one hundred dollars (5100) or less.) CJ
USE
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner I OWNER l—
so as to become subject to the Workers' Compensation Laws. ' MAIL OCCUPANCY GROUP
ADDRESS
r_
Date Applicant
NOTICE TO APPLICANT- If, after making this Certificate of CITYzz,--u 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 he 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) 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 '
_
effect. n S Na SPACESG' REQ'D �� PROVIDED
License Number Lic.Class H01ne ddress Q
I LIMITED TIME USE
Contractor Date DATE DAT C
❑ Phone _ FROM: TO:
I am exempt from the licensing requirements as 1 am a
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). FINAL APPROVAL
ESENT USE OF BUILDING
Lic.or Reg.No. Date
, 4
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE _
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- i! 0 0 0 o fj
ness and Professions Code): NO. PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the o I. I• v o o '�,
structure is not intended or offered for sale (Section
7044, Business and Professions Code). • I `r• ••
RO POSED USE OF BUILDING
I
CONSTRUCTION LENDING AGENCY
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 PROPOSED MAX. OCC.
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, TOTAL FEE
and hereby authorize representatives of this County to enter
upon the a ov entioned property fgr inspection -urpos`�SEE REVERSE OR ErLANATORY LANGUAGF
Si nat Ire of Permittee Date