HomeMy Public PortalAbout6273 ROSEMEAD BLVD_Miscellaneous__ INORKERS'COMPENSATION DECLARATION' 76M444 pLl O��fC�.p' q ®p S• ii I( p �O p r '
CE 875 (2-80) I�7� lG; 6�"P`i U P`i IL i"i tl
I_hero°t! affirm that I have a certificate of.consent"to self- COUNTY OF LOS-ANGELES BUILDING AND SAFETY DIVISION
• nsure,-or a certificate of Workers"Compensation Insurance,or
a'certified copy there (Sec. 3800,Lab C.) -
Policy No ��mpany a c�C �j FOR:APPLICANT TO FILL IN BUILDING -
- 'ADDRESS' 3 ''
ZCertified copy is herebyfurmshed. BUILDING ,jLOCALITY
ADDRESSjeo,
Certified'copy is filed with a ou ty build ing'insj,,)eciion.' NEAREST
1
depa m t. LO CA'LITY CROSS-ST.- '
Date ( Applicant �� NEAREST DISTRICT NO. G UP' TYPE PRO 5�;
D BY,
- CROSS ST., CONST. - ,-
CERTIFICATE OF EXEMPTION'FROM WORKERS'' LEGAL `
DESCRIPTION LOT NO. - BLOCK' MAP HIGHWAY COMPENSATION INSURANCE 3 STATE MAJOR sED LOCAL
NO. - (CIRCLE)'. O .
_ NO. OFBLD GS I
(This; section need not be completed-if-the work involved TRACT ^ NOW ON LOT ��•/�'� � USE'Z ONE SPECIA L'•CONDITIONS ', - _ V
by the permit is ,-fo`r one hundred'dollars_($100) or less.) USE of
' P SIZE OF LOT EXISTING BLDG: -O
I certify that'in the performance of'the work for which this `-'+
permit is Issued, I-shall-not employ any'person in any manner owNER' k i G U
so as to become subject to the'.WorkersLCompensation Laws. MAIL OCCUPANCY GROUP, 111
_ '•,. -ih, - ADDRESS 160 I • - 'Mr Y .a.
Date Applicant =
NOTICE TO APPLICANT: Ifoafter making,this Certificate of CITY NOL OCCUPANT LOAD =`
Ei emption, you' should 'become-subject 'to the Workers' APPLICATION FOR; .EX6T,HARDWARE:
•Compensation provisions of the,Labor Code, you must forth';
with comply with,such•,provisions: or this 'permit shall be TRAILER USE'E) GEOLOGY INSPECTION❑ NO Spec.'Knowl. ❑ -
deemed revoked., Panic Device
LICENSED CONTRACTORS-DECLARATION OccupprycY INSPECTION ❑
I hereb affirm that.l•am licensed under rovisions•of'Cha ter
Y p P SAFETY PERMIT ❑ (LIST ITEMS BELOW) ry0. OF EXITS
9 (commencing with•Section 7000) of•Divlsion 3 of'the Buil-' ❑. .' ',
ness and Professions Code, and my license is in full force and PARKING '
effect. SPACES REQ'D• PROVIDED
•License Number. Lic.Class
UIMITE�D TIME USE.
Contractor Date oATe oATe
FROM: •TO:
❑"
lam exempt'from the licensing-requirements as I am a
licensed architect or a registered-professional engineer slzE of No. OF , - IivsPEcroli's T ^
acting In my-professional capacity (Section 7051, Bus- EXISTING-.BLDG. C STORIES SIGNATURE
mess and Professions Code). FINAL APPROVAL.
• _ PRESENT USE OF,BUILDING ,
Lic.or Reg.No. — Date Y
HOME OWNER-BUILDER DECLARATION No. of EXISTING BUILDINGS ;
- ON LOT AND'USE - - #•�,�•'� 8�••
I hereby affirm'that' I am',exempt from the Confractoi's i;; o_o o's 'o 0,0 z
License Law for the following'reason (Section'7031.5,,Busi- 2,.,
' ness and Professions Code) NO. PARKING S
'- SPACES PROVIDED O 0 y _
❑ 1, as owner of the property, will do the work and the
structure Is' not, intended or'offered for-sale (Section'
7044, Business and Professions Code). FROPOSED USE OF BUILDING.
CONSTRUCTION LENDING-AGENCY ,
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.'C.). "
Lender's Name PROPOSED MAX. OCC.
J
Lender's Address - -PERMIT FEE
I certify. that I have read•thls application and state that the
above information is correct.I agree to comply with alII,County ISSUANCE FEE
ordinances and State;laws relating to building construction,
and hereby authorize representatives of this,,County to enter roraL FEE—''*
upon the above:mentioned property'for inipection_purp'oses. SEE.,REVERSE�FOR EXPLANATORY LANGUAGE /
Signature of Permittee' Date "'�