HomeMy Public PortalAbout5797 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) W SC E L LA N E O U S APPLICATION
hereby affirm that I have certificate of consent to self
insure, OF or a certificate of Workers'
rs'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
YolicyNo. Company FOR APPLICANTT9 FIL INti BUILDING -f—
AD
�/
❑ ADDRE
Certified copy is hereby furnished. uILDING jha��
11 ADDRESS LOCALITY
❑ Certified copy is filed with the county building inspection NEAREST
department. LOCALITY i /' i a� CROSS ST.
Date Applicant NEAREST DISTRICT NO. I GROUPTYPE ESSED BY
CROSS ST. si
CONST P C
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �_`
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY >_
NO. OF BLDGS. NO. 'CIRCLE' STATE MAJOR SECOND LOCAL (1
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.) USE OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. CrQ
permit is issued, I shall not employ any person in any manner OWNER jt• �,; G1 / � U
so as to become subject to the Workers'Compensation Laws. MAIL '�T� OCCUPANCY GROUP a
ADDRESS Q� / �TE CL
Date Applicant a CO
NOTICE TO APPLICANT: If, after making this Certificate of cITYZO� 6 L�y y f0�O OCCUPANT LOAD
Exemption, you should become subject to the Workers' gppLICA ION 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 ❑
deemed revoked. ClNOSpec. Kr10Wi.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 + l;dp/� /J
effect. �G>/LQ 0 1G✓�i�+'� '� � c.i� �.s �% PARKING
SPACES RE.'D D PROVIDED D
License Number Lic.Class 41 LIMITED TIME USE
Contractor Date DATE 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- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date 4,11
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS 1"10 FEE
ON LOT AND USE
I hereby affirm that- I am exempt from the Contractor's C
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No. PARKING V �1` L:_: _-. :. `•'-
SPACES PROVIDED _i
1�
E] 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section 01
7044,Business and Professions Code). l PROPOSED USE OF BUILDING
lenn�s .0
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 •G
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 tate l s relating to building construction, TOTAL FEE o�s6d
and hereby t orize resentatives of this County to enter
upon th b i ed property for inspect u poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat er ' Dat 1`