Loading...
HomeMy Public PortalAbout5741 ROSEMEAD BLVD_Miscellaneous__ W 1tERS'COMPENSATION DECLARATION CE 875(11-84)4 MISCELLANEOUS APPLICATION CE 87 I hereby a cert 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 i a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BcnREss / j,,� 1 , LOiCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date ApplicantRREST ���� CJ►'►, DISTRICT NO. GROUP TYPE CESSED BY �D ry - CONS CERTIFICATE OF EXEMPTION FROM WORKERS' O LEGAL d COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK "AP HIGHWAY STATE MAJOR SECOND LOCAL No. OF BLDGS. i (CIRCLE) (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 W. G E�i�� I y so•as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o Date Applicant DRESS a06 D LU EL. NOTICE TO APPLICANT: If,after making this Certificate of OCCUPANT LOAD TY a�0 No. d Exemption, you should become subject to' the Workers' APPLICATION FO EXIT HARDWARE: A Compensation provisions of the Labor Code,you must forth- I ❑ with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices El 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 Bus! NO. OF EXITS •ness and Professions Code,and my license is in full force and effect. ��(( �/ SPACESG REQ'D 'PROVIDED License Number Lic. Class ©LLP 6ALO A` LIMITED TIME USE . Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OP PROIa. TD. INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). NAL APPROVAL • LIC.OI Reg,NO. Date RESENT USE OFAONBUILDINGFIG Y/ `-� HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 142(3 FEEE_ ON LOT AND USE0 I hereby affirm that I am exempt from the Contractor's /P License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO.PARKING [[![+—[EUC i '`''^ /4`_ SPACES PROVIDED tii L.' I, as owner of the property, will do the work and the ('_ `` ; I f�tiI 1111 '9: structure is not intended or offered for sale (Section j j 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I Hereby affirm that there is a construction lending agency /,1 for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name PROPOSED MAX. OCG. Lender's Address I certify that I have read this application and state that the PERMIT FEE 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 FEE upon the above-mentioned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of PermittiS Date