HomeMy Public PortalAbout5787 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMP);NSATION DECLARATION CE 875
(11-84) MISCELLANEOUS APPLICATION
I hereby affirm 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
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING • �y
ADDRESS
Certified copy is hereby furnished. BUILDINGm QQ Q LOCALITY G
ADDRESS CJ
lad
FICertified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEARESTa-s DISTRICT NO. GROUP TYPE /
- Ic
ESSED BY
CROSS ST. kle �� ONST.' /
CERTIFK;ATE OF EXEMPTION FROM WORKERS' LEGAL \1/
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF SLOGS.
(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 /�� o_
SIZE OF LOT EXISTING BLDG. [r �'•
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 ¢_ �• ! s'
so as to become subject to the Workers' Compensation Laws. �/��� �-/A� OCCUPANCY GROUPMAIL
ADDRESS O 0a&V\,G ow-Q,
Date Applicant LU
NOTICE TO APPLICANT: If, after making this Certificate of CITY 1*0--uO. �,.� 3�kL. '� 2 OCCUPANT LOAD y
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSP6CTI0 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 andy -)
.,//�" PARKING
effect. (/ AsPAces REq•D = T PROVIDED
License Number Lic. Class LIMITED TIME USE IBJ
Contractor Date DATE DATE
FROM! To:
El 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- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING
Ila aa&d=
HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS
ON LOT AND USE .E [,-•' „��
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 n :';~.• I; ' .s
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section C' �� 3-''' _ E`I `i•=U.-I
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
PROPOSED MAX. OCG.
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,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned property for inspection purposes. 1
41 —6
SEE REVERSE FOR EXPLANATORY LANGUAGE
Date
ignature of Permittee '