HomeMy Public PortalAbout6332 ROSEMEAD BLVD_Miscellaneous__ R ,RKERS`'COMPENSATION DECT.4RATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 875
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
a certified copy thereof(Sec. 3800,Lab.C.).
BUILDING
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS 'l?
Certified copy is hereby furnished. eW6 ILD I NG DRESS DRESS 6332 Rosemead Blvd. LOCALITY
❑ Certified copy is filed with the county building inspection CALITY
NEAREST
department. TEMPLE CITY CROSS ST.
Date ApplicantAREST DISTRICT NO GR P TYPE PROCESSED BY
CROSS ST. Longden St. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP (RCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
I certify that in the performance of the work for which this sl E of Lor EXISTING BLDG. d
0
permit is issued, I shall not employ any person in any manner OWNER Mary Ina aki & Lamai Wantlan J
so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP — o
A9,DRESS 1041 San Carlos Rd.
Date Applicant - LJ�
NOTICE TO APPLICANT: If, after making this Certificate of CITY Arcadia CA NO. 446-8092 OCCUPANT LOAD z
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 provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (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 and
effect. PARKING REQ'D D PROVIDED D
SPACES
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 INS NATURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES GATUR
inessand Professions Code). FINAL APPROVAL y(�,
Lic.or Reg.No. Date RESENT USE OF BUILDING (J
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- C ( 0 2.1.0 A
ness and Professions Code): NO. PARKING (�
SPACES PROVIDED
I, as owner of the property, will do the work and the �1p #'o e o 0�8 8.,
structure is not intended or offered for sale (Section
7044,Business and Professions Code). '- ,
�, o"`:o•d o to"o e z
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING \
0 71 8=8�8
I hereby affirm that there is a construction lending agency A full—fledged quality
for the performance of the work for which this permit is Haircare salon
issued(Sec:3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
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,
and hereby authorize representatives of this County to enter TOTAL FEE
p the a ve-mentioned property for nspection purposes.
SEEREVERSEFOR EXPLANATORY LANGUAGE
Signature of Permittee Date