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HomeMy Public PortalAbout6037 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION I CE 8745(2-80) A'MISCELLNEOUSr APPLICATION CE 87 I hereby P.iprin that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insl,i e, or a certificate of Workers'Compensation Insurance,or I a certified copy*.hereof(Sec.3800,Lab.C.) Policy No. Company. BING � FOR APPLICANT TO FILL IN. wDUOResLDIS �F! p'� / dtlG�%/G1rl ❑ Certified copy is hereby furnished. Bu1LDING ��)) / ' LOCALITY ////✓✓�� ADDRESSJr(� Certified copy is filed with the county building inspection �i NEAREST department. I, LOCALITY - J /• /• C ( rI CROSS ST. ` Date AppIlCSht NEAREST DISTjtICT NO. TUI TYPE PR OCESSE BYr 1 CROSS ST. ,f i d49L_)! AVC—_ 'Vlys CONST l CERTIFI.CATE OF EXEMPTION FROM WORKERS' LEGAL D-T-H or COMPENSATION INSURANCE DESCRIPTION LOT NO. !S BLOCK MAP H,IGM WAY Nb. (CIRCLE) STAT AJOR SECOND LOCAL 8 V NO. OF BLDGS. LL (This section need not be completed if the work involved TRACT O NOW ON LOT USE'ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) W 1U SIZE OF LOT SOX ,3 EXISTING BLDG.USE OF - I certify that in the performance of the work for which this 1 O permit is issued, I shall not employ any person in any manner OWNER so as.to become subject to the Workers' Compensation Laws. MAIL1,116 �// O� OCCUPANCY GROUP © I W ADDRESS O 6 a Date Applicant I Cn NOTICE TO APPLICANT: If, after makingthis.Certificate of CITY-72,/o TEL. z -2,/✓jP[( C �T� No. b-,3o I' OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR I EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with Such provisions Or this permit shall be TRAILER USE GEOLOGY INSPEiCTION C 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 PERMIT1�1 (L.IST ITEMS BELOW) ' y LI NO. OF EXITSEJ 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and PARKING. effect. REQ'D O PROVIDED ` SPACES License Number' Lie.Class `� i LIMITED TIME USE ' Contractor Date. GATE GATE FRo'M Elam exempt from the licensing requirements as I am a : ro: licensed architect or a registered professional engineer SIZE OF L� NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. I .cl • STORIES I SIGNATURE• iness and Professions Code). PRESENT USE OF BUILDING /D FINAL APPROVAL ' Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS (. I ON LOT AND USE _ • v ` 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. PARKINGSPACES PROVIDED d O n`n' I, as owner of the property, will do the work and the c�V F, structure is not intended or-offered for sale (Section #` o'0 0 0 7j L1 7044., Business and Professions Code). PROPOSED USE OF BUILDING y�ao�yby � 1 CONSTRUCTION LENDING AGENCY 2G'G625r1 I hereby affirm that there is a construction lending agency o 0 0 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. f Lender's Address PERMIT FEE i 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 ordinances and State laws relating to building construction, TOTAL FEE and hereby thorize repr entatives of this County to enter upon the ve-mention p erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i Si t re of Permittee Date