HomeMy Public PortalAbout5821 ROSEMEAD BLVD_Miscellaneous__ „ iWORKERS'COMPENSATION DECLARATION 7185cE sis4(ii-e4) MISCELLANEOUS APPLICATION
I herebya'ca f itl that I have a certificate of consent-tonc self COUNTY OF ]LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or ertificate of Workers'Compensation Insurance,or
a`certified copy thereof(Sec.3800,Lab.Q.
PoliNo. Company BUILDING
Policy P Y FOR APPLICANT TO FILL IN ADDRESS
FiCertified copy is hereby furnished. BUILDING 'Demme. si
ADDRESS O LOCALITY
Certified copy is filed with the county building inspection LOCA'LITy � ` �.1 NEAREST
department. 1�I'�✓C lli-1 � CROSS ST.
Date Applicant NEAREST DISTRICT No: GROUP TYPE P CESSED BY
CROSS ST. CONST
CERTIFICATE OF EXEMP. ION FROM WORKERS' LEGAL
COMPENSATIO INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY S AT.E MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF BLDGS.
(This section need not be co pleted if the work Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITION
by the permit is for one hu dred dollars ($.100) or less.) iJSE of
.i SIZE OF LOT �' - EXISTING BLDG. a
I certify that in the performs ce of the work for which thistf ; o
permit issued I shall not a loy any person n any manner I
P =
so as to become subject to th Workers' Compensation Laws. OWNER �h �; _ `� OCCUPANCY GROU o
Date A h ADDRESS P (; i�t� T� T 1ot�V W
PP t _
NOTICE TO APP•L'ICANT: f,after making this Certificate of CITY L�� NO. D 3 i OCCUPANT L AD C°„
Exemption, you should ecwme subject to the Workers' z
Compensation provisions f the Labor Code,you.must forth- APPLICATION FOR EXIT"HARDWAR :
with comply with such provisions or this permit: shall be ` TRAILER USE GEOLOGY INSPECTION No Sp . Knowl.
deemed revoked.
LICENSED CO RACTORS DECLARATION OCCUPANCY INSPECTION p Panic evices
I hereby affirm that I m licensed under provisions of Chapter SAFETY PERMI LIST ITEMS'HELOW)
9 (commencing with ction 7000)of Division 3 of the Busi i No. F EXITS
ness and Professions ode,and my license is in full force and 7
effect. i i �h PARKING REq'D ,PROVIDED
SPACE8
License Number Lic. Class r��f�� (/ LIMITED TIME USE-
Contractor Date • �' 166 N � GATE• OATS
t FROM: TO:
D I am exem from the licensing requirements as d am a
licensed ar hitect•or a registered professional engineer SIZE of No.of . INSPECTOR'S
acting in y professional capacity (Section 7051, Bus- EXISTING BLDG, t STORIES SI 6 TORE
inessand ofessionsCode).. FINAL APPROVAL
Lic.or Reg. Date ( PRESENT USB OF BUILDING
H ME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS °,'�... ®
.i ON LOT AND USE '•}
I hereby affirm that I am exempt from the Contractor's '• :l`s I-,
License aw for the following reason (Section 7031.5, Busi ':; �I rl;,, .' w;_I-; IYI r J41
ness Professions Code): NO.PARKING
I as owner of the property, will do the work and the i SPACE8 PROVIDED �'1/✓I E:ii]•� y j5; /���
{acture is not intended or offered for sale (Section /
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCYPROPOSED USE OF BUILDING
I ,
I Hereby affirm that there is a construction lending agency ;
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name
40 PROPOSED MAX. OCC. '
Lender's Address
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 TorAi.FEE
upon e-mentioned property for inspection purposes.
^_ -SEE REVERSE FOR EXPLANATORY LANGUAGE
�l Q� /el—IT,Q'�
W�' Signature of Permittee Date