HomeMy Public PortalAbout6143 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION ICE 875(2-80) MISCELLANEOUS
ISCE AAGOVS APPLICATION
I hereby aff�gm that I have a certificate of consent to self I insure, or a certificate of Workers'Compensation Insurance,or BOUNTY OF LOS ANGELES7- BUILDING AND SAFETY DIVISION
6
a c�il�ed copy thereof(Sec.3800,Lab.C.)
Policy No. .Company CANTTO FILL IN BUILDING
ADDRESS (D/
Certified copy is hereby furnished. BUILDING LOCALITY
ADDRESS
❑ Certified copy is filed with the county building inspection/ NEAREST r
LOCALITY department. CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE 1PROCPSEP BY
�^ CROSS ST. D CONST./,,--"CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �Of_
e
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP //��'7 NIGH WAv
NO. C;70C (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLOGS. >-
(This 50CtlOn need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0
by the permit is for one hundred dollars ($100) or less.) ,(y/_ 1 V
USE OF ,�w�`
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. tlr
permit is issued, I shall not employ any person in any manner OWNER I /` O
so as to become subject to the Workers' Compensation Laws. �� OCCUPANCY GROUP U
MAIL Q
ADDRESS CL
LLI
Date Applicant
TEL. _ OCCUPANT LOAD Z
NOTICE TO APPLICANT: If, after making this Certificate of CIT No.
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 provisigns or this permit shall be TRAILER USE GEOLOGY INSPECTION
deemed revoked. ❑ ❑ No,Spec. Knowl. El
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIO Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000)of Division 3 of the BusiAlk
-
ness and Professions Code, and my license is in full force and PARKING
effect. SPACES ' REO'D PROVIDED
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 SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
,ic,or Reg.No. Date
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 / ( ! 9 3 23.2 A
SPACES PROVIDED (// t 1
I, as owner of the property, will do the work and the .`( ! i D a o 0 3 0
structure is not intended or offered for sale (Section , If
7044, Business and Professions Code). PROPOSED USE OF BUILDING 2 D - 6250
CONSTRUCTION LENDING AGENCY 0 0 0 6 2 5 0 5
I hereby affirm that there is a construction lending agency
for the performance of the work for wJtich this permit is !) 3, 1 0'-82
issued(Sec. 3097,Civ.C.).
Lender's Name PROPOSED MAX. OCC.
ender's Address PERMIT FEE l
I ertify that I have read this application and state that the
b ve information is correct.I ag .to comply with all County ISSUANCE FEE iV
finances and State a rel to building construction, TOTAL FEE a
a hereby aut rize re es to iv of this County to enter r
o the Dov enti rop r for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
I� �Lp3t`�
Signature of Permit t Date