HomeMy Public PortalAbout5753 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affirm thgt I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or'a certifiLrate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lam.C.
P❑olicUPC �pany-- C 1� FOR APPLICANT TO FILL IN BUILDING
��//'' ADDRESS �7 ✓
Certified cop Niereby furnished. ILDING '/ LOCALITY
ADDRESS v
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY F ?�� CROSS ST.
Date Applicant EAREST DISTRICT NO. GROUP TYPE CESSED BY
CROSS ST. 7r�' �D® CONSTV
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NO.
HIGHWA
CI CLE~ STATE MAJOR SECOND LOCAL d
e work involved TRACT NOW
(This section need not be completed if the ilved NO. OP SLOGS.
LOTT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars (S100) or less.) USE OF
SIZE OF LOOT EXISTING BLDG.
a
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. AIL ^ J� OCCUPANCY GROUP
1T_TW
ADDRESS / Cy, y
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of ITY �
A-r � 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 USE GEOLOGY INSPECTION No Spec. KnOWI. ❑
deemed revoked. Panic Devices ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (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 //�G PANKING.
effect. SPACES ' REQ'D PROVIDED
License Number Lic.Class EffG S50 ry LIMITED TIME USE
Contractor Date D ATE DATE
❑ FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting In my professional capacity (Section 7051, Bus- EXI TING BLDG. STORIES SI22��
TO
iness and Professions Code). �p�J FINAL APPROVAL
Lo PRESENT USE OF BU�LDFNG g
Lic.or Reg.No. Date iL 1
X=Ad ✓T Sv s—
d p
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGSON LOT AND USE
YOI
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): sPwces PROVIDED
ElI, 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). PROPOSED USE OF BUILDING
J �
CONSTRUCTION LENDING AGENCY a
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 Rt7/®
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, Aoo
and hereb authorize representatives of this County to enter TOTAL FEE CK
upon th above- en i ed property for inspection,pyrpose SEE REVERSE FOR EXPLANATORY LANGUAGE
ar`JO/�y/�
S' re of Permittee Date