HomeMy Public PortalAbout5829 ROSEMEAD BLVD_Miscellaneous__ j 1\nRI:LRS'COMPENSATION DECLARATION CE 87 4 M ISCELLAN EOUS A PLIC
CE 875 (11-841
# I hereby 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 -
I a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN AO OR Ss 2
Certified copy is hereby furnished. g BUILDING S
AD OR ESS LOCALITY
1 1
Certified copy is tiled with the county building inspection'g LOCALITs� /�, Qf1 NEAREST
department. �.L CFo Ca OSS ST.
Date .applicant NEAREST � 31STRIC NO. GROU TYPE CESSED BY
CROSS ST. CONST _iir.
i
CERTIFICATE OF EXEMPTION FRU?(«'ORI:ER5' LEGAL
COMPENSATION INSURANCEDESCRIPTION LOT NO. BLOCK MAP HIGHWAY
No.
NO. OF (CIRCLE) STATE MAJOR SECOND LOCA.L
(This section need not he completed if the work involved TRACT NOW ONBLD GS.LOT USE ZONE SPECIAL CONDITIONS
by the permit is for Line hundred dollars ISM) or less.)
USEXISETING BLDG.OF
1 ,:ertify that in the performance of -lie••I•nrk :ur which :Itis SIZE OF LOT
permit is issued. I shall not employ an), person in any manner X OWNER �^
so as to become subject :o the Workers* Compensation Laws. n OCCUPANCY GROUP
t X :,AIL
Date—__ p . ADORESS
�
rlicant � nI
NOTICE TO APPLICANT: If, .titer making ;Itis Certificate ui X cIT'�,_Va d_VNO., y�10��0)3� OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR E CIT HARCWARE.
Compensation orovistons of the Labor Code. ou must forth-
! with comply Keith �ucn provisions `r tis -e:mit inall be -RAILER •JSE ' I GEOLOGY INSPECTION I �Jo Spec. Know[. G
deemed reeoked. — —
:V
LICENSED CONTRACTORS DECL.kR.kTION OCCUPANCY INSPECTION B I Panic Devices El
1 hereby affirm that I am licensed under provisions of Chapter
n. I SAFETY PERMIT (LIST ITEMS BELOW)
9 twmmencin¢ with Section 10001 of Division 3 of fife Bust- No. OF EXITS
ness and Professions Code,and my license is in tall force and
effect. PARKING RED PROVIDED I I
Jf SPACES
License Numbe: Lie. Class
LIMITED TIME USE
n Contractor Date DATE OA re
2
I :Im a%emp[ from hr !icrnsing truuire:nen[s :, 1 n i wqoMj
i licensed architect or a registered -rofessiunal an;inee: 'SIZE OF uO. OF INSPECTORS
Z acting in ml- Drotel$1Unal cavadc. •section Bus- EX157:YG 3L3G. STORIES SIGNATURE
inessand P:ofessiunsCode t.
-RESENT USE OF 3UILDING FINAL APPROVAL
5 Lic.or Rr>•. N,L---- —. Date ------• .
x )
HOME OWNER-BUILDER DEC:LARAMON VO. OF EXISTING BUILDINGS �p ���$
ON LOT AND USE I �
[ hereby affirm hat i .un exempt fmm the Contractor's
1 License Lave for the falloivine reason -Sec-ion -931.3. Susi- i
ness and Professions Codec: NO. PARKING
I, as owner of the property, will do the work Ind :he I SPACES -ROVIDED
structure is not intended or offered for :ale -Section
1 7044.Bu6ness and Professions Codei.
X PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY i.
I hereby affirm that there is :I construction lending ,Lency
t for the performance of the work for whichthis permit is
issued(Sec.3097.Civ.C.1.
Lender's Name t—I
PROPOSED MAX. OCC.
1 Lender's Address - PERMIT FEE 25.00
I certify that I Ilaee read this application and state that the
' above information is correct.I agree to Comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction.
aitd hereby aur orize reprc ntaR,*•s of this County to enter TOTAL FEE 25.00
n h
upoe abovef nentioi d rt per fur inspection purpusea. t
! j % �j _ SEE REVERSE FOR EXPLANATORY LANGUAGE '-MI