HomeMy Public PortalAbout5819 ROSEMEAD BLVD_Miscellaneous__ WORKLRS'COMPENSATION DECLARATION CE 875(11-84) M ISCELLANEOUS 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 BADDRESS UILDING G
Certified copy is hereby furnished. BUILDING I� LOCALIT
SY
ADD ES ./'
I K
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE PR ESSED BY
CONS
CROSS ST.
CERTIFICA'T'E OF EXEMPTION FROM WORKERS' LEGAL �
COMPENSATION INSURANCE DESCRIPTION I 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
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
so as to become subject to the Workers' Compensation Laws. MAIL ^ C� T OCCUPANCY GROUP OZ
ESS 0q0 `P
..0 ! fH F Z�:] 65
Date Applicant 4J
NOTICE TO APPLICANT: If, after making this Certificate of CITY aC r,oL 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 or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
❑ ❑ No Spec. Knowl.
deemed revoked.
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 I
effect. GreenPARKING REWO PROVIDED 1
SPACES J
License Number Lic. Class 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. STORIES S NATURE
iness and Professions Code). /gyp
PRESENT USE OF BUILDING `J ! D FINAL APPROVAL 110
Lic.or Reg.No. Date V
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE `_ � jry /Cti�
I hereby affirm that I am exempt from the Contractor's ��
U u/Lf 74
License Law for the following reason (Section 7031.5, Busi- IQ � 51279 1 PM 3°52
ness and Professions Code): NO. PARKING
0 I, 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).
bl
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING /JeJC!7
I hereby affirm that there is a construction lending agency T -Fo !rte a
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 d-0
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 Litho 'We representatives of this County to enter TOTAL.FEE / 0-10
a vf
' a roperty for inspection purposes.
-7SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of PermittAe Date