HomeMy Public PortalAbout5809 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76CE 8754(11-84) MISCELLANEOUS APPLICATION
I he>eby 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
ADDRESS
Certified copy is hereby furnished. uILDING Q/6'' /��f �• LOCALITY
ADDRESS 7 Q� /-()JS( -Q�L.
DCertified copy is filed with the county building inspection OCALITY / NEAREST
department. CROSS ST.
Date Applicant NEAREST / DIST®�, G��,,OOUP TYPE PR CESSED B
CROSS ST. Y
�fTi�')Lc,J' 2
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. OF BLDGS. NO. (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
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this , „ „�� CD
permit is issued,I shall not employ any person in any manner 1, OWNER - cC 4 e 53
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ail
oDate Applicant ADDRESS w
TEL. OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of clTr No.
.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 or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. ❑ E] No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El
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 9
effect. PARKING SPACES REq'D D PROVIDED I
J
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
DI 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 SIGN TORE
iness and Professipns Code). FINAL APPROVAL fD�� ^��
PRESENT USE OR BUILDING
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
License Law for the following reason (Section 7031.5, Busi- �'•-�=- `=
ness and Professions Code): NO. PARKING - .a Q
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 j, (
47
for the performance of the work-for which this permit is
issued(Sec. 3097,Civ.Q.
Lender's Name
Lender's Address
PROPOSED MAX. OCC.
'
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 ��oo
upon tl entioned property for inspection pur oses,
SEE REVERSE FOR EXPLANATORY LANGUAGE
- ! G
Signature of Permittee Date