HomeMy Public PortalAbout5799 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION '76M444
CE 875(11-84) MISCELLANEOUS PPLICATION {�
�I hereby sffirm °thlt I have a certificate of consent to self COUNTY OF LOS ANGELES B ILDING AND SAFETY DIVISION L1
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
pDDRE53
Certified copy is hereby furnished. UILOING /V C Q/ol lu LOCALITY
ADDRES
Certified copy is filed with the county building inspectionocALITY NEAREST
department. CROSS ST. -
Date Applicant NEAREST �]� DISTRICT NO. GROUP TYPE P CESSED BY
CROSS ST. Las Vitt" P--. �D O CONST.,/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Q I/
COMPENSATION INSURANCE I DESCRIPTION I LOT NO. BLOCK MAP. HIGHWAY STATE MAJOR SECOND LOCAL
NO. OF BLDGS. NO.1, (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 n/
Q^ a
I certify that in the performance'of
OF LOT EXISTING BLDG.f the work for which this C� i CD
permit is issued,I shall not employ any person in any manner OWNER ue
so as to become subject to the Workers' Compensation ,p„Laws. MAIL OCCUPANCY GROUP
ADDRESS 1--'
Date Applicant 200 e� Z 'fit 1�o0r
NOTICE TO APPLICANT: If, after making this Certificatg of CITY NO. 213,4317,PlD46 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPSCTIONEI
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 and
effect. T PARKING REQ'D D PROVIDED
SPACES
License Number Lie. Class wt�n` � a.E. 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. 12- 12 �, ' STORIES SIGNATURE
]Hess and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING WVve— �'• ^
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's 6
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 SPACES PROVIDED
structure is not intended or offered for sale (Section 7!
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY FROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency G
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX.OCC.
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 o76—, Of
upon the above--mentioned pro erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatuigof Pe ittee Date