HomeMy Public PortalAbout5807 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875
(11-84) M I'SC E L LA N EO U S 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
DDRESS
Certified copy is hereby furnished. X BUILDING O OS - • 1D Ir�GY� LOCALITY
ADDRESS
DCertified copy is filed with the county building inspection LOCALITYr 1- NEAR EST
department. T `Y?LG C-17 cROss ST.
Date Applicant NEAREST DISTRICT NO. G OUP TYPE ESSED BY
CROSS ST. L�`I (� �� CONS
T.//
CERTIFICATE OF EXEMPTION FROM WORKERS' Le GAL LI rJ (/
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP CIRC AY
NO. OF BLDGS. (clRcl.e
STATE MAJOR SECOND LOCAL
Ro. )
(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
_ (� a
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. o
permit is issued,I shall not employ any person in any manner OWNER G ` y &Hgt0 �' y
so as to become subject to the Workers' Compensation Laws. MAIL //�y� OCCUPANCY GROUP o
ADDRESS �{� � ,��.TK �V'
Date Applicant
NOTICE TO APPLICANT: If,after making this Certificate of CITY �ZNO. OCCUPANT LOAD N
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 INSPECTION ❑ 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 and
effect. ]� /'/��✓ 7 PARKING
SPACES REq'D D PROVIDED O
License Number Lic. Class
LIMITED TIME USE
Contractor Date O ATE DATE
I am exempt from the licensing requirements as I am a FROM: TO:
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 / `°-t =
PRESENT USE OF BUILDING 10 Z -"'
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS O C`� -_ :'?-I" �.j , in.
ON LOT AND USE 1 " - `• "• -'
I hereby affirm that I am exempt from the Contractor's 0 � , ; ';:.:t"?
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING 1(�
ElI, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency Ars .,
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 91�
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.
Z_SEE REVERSE FOR EXPLANATORY LANGUAGE
/\ _1 Signature of Permitte Da e