HomeMy Public PortalAbout5800 ROSEMEAD BLVD_Miscellaneous__ 1tUxl;.Lltb'�U.%IYJ AJA11U\ IJLILAllA11U.\ CE875(11.84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tsell 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 N xm0 pany lif& ZO-1iIT4 FOR APPLICANT TO FILL IN ADDRECCOSC
2 Certified copy is hereby furnished. ncneesS SJOSCM� D• LOCALITY
DCertified copy is filed with the county building inspection LOCALITY -tea WY 7yo y- /�' NEARESY
departments IM1,Lf CROSS S".
/�
Date C. G Applicant `CY"r, NEAREST /In 1/� DISTR NO, GROUP CONST. // ESSED HY
CROSS ST. IP , V �/I iT ,-(rITYPE J/
CERTIFICATE OF EXEMPTION OM WORKERS' LEGAL VU
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
OF BLDGS.
NO. (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZON SPECIAL CONDITIONS
NO.
by the permit is for one hundred dollars (SI00) or less.) IE OF
E
SIZE OF LOT XISTING BLDG.
I certify that in the performance of the work for which this _
permit is issued, I shall not employ any person in any mannern I OWNER zykc T40
so as to become subject to the Workers' Compensation Laws. MAIL .//� OCC JP NCY GR Uri
Iq ADDRESS 7-
Date Applicant
TEL' OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of `�clrY No. (yZ(p'As
y; _
Exemption, you should become subject to the Workers' I 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 E] No Spec. Knowl. /9/79
deemed revoked.
t Panic Devices
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION j�
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. PARKING REO D D PROVIDED I J
it SPACES l�
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
E •
I am exempt from the licensing requirements as I am a FROM: TO: INSPRS
-
licensed architect or a registered professional engineer SIZE OF NO. OF sIG URE
acting in my professional capacit-, (Section 7051, BUS. EXISTING BLDG. STORIES
iness and Professions Code). FINAL APPROVAL Q��j
PRESENT USE OF BUILDING tY� ((
Lic.or Reg.No. Date ,
HOML OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
I ON LOT AND USE -
I hereb} affirm that 1 am exempt from the Contractors
License Law for the following reason (Section '7031.5. Busi-
ness and Professions Code): NO. PARKING
'SPACES PROVIDED
I. as owner of the property. will do the work and the
structure is not intended or offered for sale (Section
7044.Business and Professions Colic).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agen(y
for the performance of the work for which this permit it I
issued(Sec.3097.Cit'.C.). ( ,
Lender's Name
PROPOSED MAX. OCC. )�
Lender's Address )
wS �
I certify that 1 have read this application and state that the PERMIT FEE 25.00 C) 1�
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 25.00
upon the above-mention1d property for inspection purposes.
���/,��(, SEE REVERSE FOR EXPLANATORY LANGUAGE
2S
Sign ure of tee Date =3