HomeMy Public PortalAbout5809-5819 ROSEMEAD BLVD_Miscellaneous__ WORF COMPENSATION DECLARATION CE 875(11-84) IV CELLANEOlJS APPLICATION r
rr CE 875
I hereby af': hat I have a certificate of consent to self IJ
insure, or a cermicate of Workers'Compensation Insurance,or
I COUNTY OF LUu aNGELES BbILDING AND SAFETY DIVISIOi'
a certified co thereof*Pc.3800,yLabb aQ
Policy NdY Company;-7- FOR APP L CANT TO FILL- SS
eAD
IN BUILDING _C�fA 1
DRE
869
Certified copy is hereby furnished. BUILDINA
G 04 LOCLITY J j
ADDRESS
DCertified copy is filed with t;hVnty_11pUm1g inspection LOCALITY NEAREST f
de rtBrit. e, CROSS ST.
DateApplicant NEAREST DISTRICT NO. GROUP TYPE�7 PRO D HY
CROSS ST. - (yam —� CONST
.q
CE IFI .ATE OF EXEMPTION FR M KERS' LEGAL v
COMPENSATION INSUR ' DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR 6C0 NO L CAL
NO. (CIRCLE)' NO. OF BLDGS.
(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 ESTING BLDG.
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner OWNER S'i
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
F-•
Date ADDRESS 8 Applicant
TEL. LU
NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. i OCCUPANT LOAD
Exemption, you should become subject fo 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.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ I 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. PARKING E
Rq•D PROVIDED
���� 1
License N ber�`�� 0 0(�LSPACESic. Class LIMITED TIME USE
Contra "thficensmg
to DATE DATE
FROM: TO:
El am exempt requirements as I am a
licensed architect or a registered professional engineer (SIZE OF NO. OF t INSPECTOR 3
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL.
LIC.oI Reg.No. Date
HOME OWNER-BUILDER DECLARATION :NO. OF EXISUSS BUILDINGS
I hereby affirm that I am exempt from the Contractor's SON LOT AND
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING ACf, .a L
I, as owner of the property, will do the work and the SPACES PROVIDED 3
313 � uIjIZ
structure is not intended or offered for sale (Section
7044,Business and Professions Code). i ITEMS
EMS
, '
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING TOTAL ISL 9•�3
-O0
I hereby affirm that there is a construction lending agency I E93.(0
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). CHANGE ,1313
Lender's Name ,
PROPOSED MAX. OCC.
Lender's Address pp� 0000-01101
�1r {'��
PERMIT FEE V� S.��tJL1-•'�II:J.L 3f9/9.l•
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 3.0 5282 1 A1110:27
ordinances and State laws relating to building construction,
and hereWr authorize representatives of this County to ente TOTAL. FEE 3 . 0
upon th e-mentio perty for inspection pur . ses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
9777Y-70
Signatu erm.' a ate