HomeMy Public PortalAbout5828 ROSEMEAD BLVD_Miscellaneous__ ti�VVORKERS'COMPENSATION llECLARATION 76nn444
MISCELLANEOUS APPLICATION
CE 875(11-84)
I liereby-affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS ,
Certified copy is hereby furnished. BUILDING 5D g V L ) LOCALITY
ADDRESS
DCertified copy is filed with the county building inspection LOCALITY NEAREST
department. Y L CROSS ST.
Date Applicant NEAREST DIEXW2 G Uk TYPE / PRSED BY
CROSS ST. �j �� 51 CONST. RnSED
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTIHIGHON LOT NO. ! BLOCK MAP NO. (CIRCLE)AY STATE MAJOR SEC D LOCAL
NO. OF BLDGS.
(This Section need not be completed if the work involved TRACT a NOW ON LOT USE ONE SPECIAL TI
by the permit is for one hundred dollars ($100) or less.) (/Z�J 7
USE OF // I
SIZE OF LOT EXISTING BLDG. Iy' '�
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 OWNER I- /5 COe-'O!G
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP _ o
ADDRESSCX
sL.l,O V
Date Applicant I+I
NOTICE TO APPLICANT: If, after making this Certificate of CITY%,gy NDL ZZ OCCUPANT LOAD
Exemption, you should become subject to the Workers'
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❑ 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 andPARKIN
�I �I
effect. -xm/r Fa
SPACES Cs REQ D �— 1 PROVIDED
SPACE
License Number Lic. Class als-tia. ,L1te 1—',ZZ&4W &XmieleviLIMITED TIME USE
Contractor Date Lr - !li Z
PROM: TO:
DATE DATE
FI am exempt from the licensing requirements as I am a S lvmr e slaw v- �
licensed architect or a registered professional engineer SIZE OF NO. OF I SIGE TURK in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date
PRESENT USE OF BUILDING
(C
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
❑ 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).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING L91 8.GA
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is # 0 0 0 0 3 0
issued(Sec. 3097,Civ.C.).
Lender's Name I - - 8(150
Lender's Address
PROPOSED MAX. OCC.
o - 80.5070:
PERMIT FEE
1 certify that I have read this application and state that the '
above information is correct.I agree to comply with all County ISSUANCE FEE S Q'z16-88
ordinances and State laws relating to building construction, O S
and hereby authorize representatives of this County to enter TOTAL FEE
�upo the above-mentione�d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�CQ ��LFI�Le ne�o�.
Signature of Permittee Date