HomeMy Public PortalAbout5731 ROSEMEAD BLVD_Miscellaneous__ e, WORKERS'COMPENSATION DECLARATION cE eis4(t t•B4) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �•.
Lnsufe, or'a certificate of Workers'Compensation Insurance,or
a.cyrtified c®py thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING 3
XX ADDRESS LOCALITY
Certified copy is filed with the county building inspection LOCALITYNEAREST
department. XX ( CROSS ST. `
Date Applicant NEAREST DISTRICT NO. GROUP CONST. PR -SS ED BY
CROSS ST. � �
CERTIFICATE OF EXEMPTION FROM WORKERS' 4 LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. LOCK MAP NIGHwA I STATE MAJOR SECOND LOCAL
NO. ICI
NO.OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE BONE 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
permit is issued,I shall not employ any person in any mannellEX, OWNER Of buildingS
so as to become subject to the Workers'Compensation Laws. OCCUPANCY GROUP
MAIL
ADDRESS asse .
Date Applicant 41
NOTICE TO APPLICANT: If,after making this Certificate of CITY I!E - Nc�. -a a_6 3 OCCUPANT LOAD N
Exemption, you ihould become subject to the Workers' AP CATION FOR E}GIT HARDWARE:
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCYPanic Devices
INSPECTION❑
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 altX Name of business . PARKING r �t
effect. REq'D 1 PROVIDED 1 �j
SPACES
License Number _.____ Lie. Class LIMITED TIME USE
Contractor Date DATE DATE
PROM: TO:
1:11 am exempt from the licensing requirements as I am a
licensed architect or a re stered professional en ineer SIZE OF NO.OF INSPECTOR'S
registered p li SIGNATURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code). FINAL APPROVAL
Lie.or Reg.No. Date PRESENT USE OF BUILDING
HOME OWNER-1111ILDER DECLARATION No. OF EXISTING BUILDINGS A
ON LOT AND USE `��'
I hereby affirm that I am exempt from the Contractor's O
License law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO.PARKING
1, as owner of the property, will do the work and the I SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCI'ION LENDING AGENCY PROPOSED USE OP BUILDING
I hereby affirm that there is a construction lending agency
I^T =b
for the performance of the work for which this permit is :•.; � I
issued(Sec.3097,Civ.C.).
Lender's Name
PROPOSED MAX.OCC. •Ti
Lender's Address
PERMIT FEE .•
I certify that I have read this application and state that the i'
above information is correct.1 agree to comply with all County ISSUANCE FEE
ordinances and State laws rely' to building construction, L. 25.00
+
and hereby authorize representat- s of this County to enter TOTAFEE =! '`
Upon th a ve-mentioned p for inspection purposes
I I 7�— J EE REVERSE FOR EXPLANATORY LANGUAGE
XX X >