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Home My Public Portal About5402 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 I`herebi' affi?rp-!hat 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.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ��II ADDRESS Certified copy is hereby furnished. BUIL°ING ^� LOCALITY AD DR'E SS o, U- RotJ cv e. & 1 �[. ❑ Certified copy is filed with the county building inspection LOCALITY e NEAREST department. JC_, ( br cRoss ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P OCESSED BY CROSS ST. /•% �/ CONST. L� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE F SIZ F LOT EXI BLDG I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner WNER 4 y so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP _�+ o ADDRESS BIZ C~.7 Date Applicant ,,, TEL OCCUPANT LOAD n NOTICE TO APPLICANT: If, after making this Certificate of CITY Q( No. ISS —�t7(7 cn Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- '-7/,P, APPLICATION FOR EXIT HARDWARE: with comply with such provisions oI this per-nit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 pJ�� effect. (�th� I/✓r �(� CI PARKING SPACES REq'D D PROVIDED License Number Lia Class t?f�� ►'� U'n-` � �" -t C �/ �"r LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer, SIZE OF NO. OF INS; oR s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES sI AT E iness and Professions Code). FINAL APPROVAL /-PRESENT USE OF BUILDING /�7 Lic.or Reg.No. Date � � � � E, HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ► \ c ON LOT AND USE = r 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 ElI, as owner of the property, will do the work and the SPACES PROVIDED inf� structure is not intended or offered for sale (Section 1Y 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDINGCar V 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. 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, �yJ� and hereby authorize representatives o this County to enter TOTAL FEE o upon the above-mentioned erty or nspection purposes. + SEE REVERSE FOR EXPLANATORY LANGUAGE 9 4 Signature of Vrmittee Date II ` WORKERS'COMPENSATION DECLARATION 875 �;1�-841 MISCELLANEOUS APPLICATION r, CE 875 CE I hereby affirm that 1 have. a certificate of consent to self -r , Insure.:.)r a-certificate of\Yorkers•Compensation Insurance,or COUNTY OF LOS .ANGELES BUILDING AND SAFETY DIVISION a Certified copy thereof iSec. 3800, Lab. C.1. -- Policy No._—Company FOR APPLICANT TO F!LL IN ADDRESS ❑ Certified coPy is hereby furnished. UILDING /,�^ r' BAD OR ESS LOCALITY I Certified cope is tiled„uth the count, building inspection LOCALITY NEAREST Temple department. Tle City P J CROSS ST. Date —Applicant NEAREST DISTRICT NO. GROUP TYPE (PROCESSED SY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM '\ORKERS' LEGAL t_ ( ()NIPFNS:ITION INS( RANC!_ DESCRIPTION LOT NO. 3LCCK IrNAv ICH.Av (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF Si (This section need not he completed If the work Involved 1 TRACT NOW ON LOT USE ?ONE PECIAL CONDITIONS by the permit is for one hundred dollars +SIO01 or less.) t OF ' SIZE OF LOT I USE EXISTING I certify that in the performance ct -he 'v . erb: :ur 'which :his Si � permit is issued. I saidil not emPley any ae-aut :n in,- manner OWNER so as ro become subiiect to the II,orkers' t.rmpensatien !.a,cc. .`Ri AIL OCCUPANC'' •(ROUP _ ADORESS Date Applicant NOTICE TO APPLICANT: If. :uter making '!:is Cor*i icate ,f $j c,r NC. f C)CCUPIN LOAD Esemptio-t. you should become suiiect ._ -he 1i Compensation provisions of the I_aber ',',)de You must torth_ AP°L!CATICN F =X!' HAar_I;,i:sF`. - i with. compiv \Wada such !)ro,isinn, c- .hi:< -ermit ,hail be -RAILER JSE :� — ec. L__J oked. ,EO LJGY :NSPE TION 77 deemed rc, NO soI�; C'/I L-J LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices, I hereby affirm :hat 1 am licensed under previsions of Chapter - j C SAFETY PERMIT y (LIST ITEMS 3119 (commenling xvith Section 000) of Division 3 .it the Bust- NO. OF EXITS ness and P-ntessions Code. and m_v license is in foil force and (� effect. � PARKING REO O I PR O`✓ID ED N !/ SPq CES License '�urnber Lic. C!ass LL LIMITED TIME USE Contractor -- Date—___ _ TE w -- ,A z »n: To: I am exempt from the iicensinz reauLements as I am .I m 1 licensed architect or a registered processional engineer SIZE OFNO. GF INSPECTOR'S z actino in ms• prote sional ra it} ��:Iron -I` 1. Ru.- EXISTING BLDG. STOR1 7; SI NATURE inessaiid P-ofessictis Idol. 'INAL APPROVAL— - J oR ccE NT USE OF BUILDING If Lic.or Rea. No. _ D;ite HOME O«NFR-BUILDER DECLAR.MON NO. OF EXISTING BUILDINGS 0 n IiiContractor / V ON LOT AND USE r I affirm that I am exempt from the Contractors 1 License Lasa for the followin_, reason "Section -t_t31.5. Busi- ness and P'eresslons Code): NO. PARKING 1, as owner of the property, swill do !lie ,work and the SPACES PROVIDED structure is not intended or offered for :ale (Section 1 `�ri1_l l i•:-•tL,• :'1": - 1 7041.Businessand Professions Codi .YL._I 1 +'::M, CONSTRUCTION LENDING Ai PROPOSED USE OF BUILDING 1 Iterebw affirm that there is a construction lending :I-cncv for the performance of the .work for which this permit is issued (Sec. 3097•Civ. C.). Lender's Name PROPOSED MAX. OCC. Lender's Address I I certify that I have read this application and ,tate that the PERMIT FEE 25.00 above information is correct. I agree to comply.with all County ISSUANCE FEE ordinances and Slate laws relating to building construction. and hereby authorize representatives o this County to enter TOTAL FEE 2x,_00 1 upon ovc-menti ed property r inspection purposes. SEE REVERSE- FOR EXPLANATORY LANGUAGE- I Signature o Permittee Date WORK ERS" C(11\IPFNSAIION DLCLARALION "t'^11 MISCELLANEOUS APPLICATION hereby affirm that I have a cerlil'icale of consent (o >eu COUNTY 01 I.OS ANGL1_TS BUILDING AND SAFETY DIVISION insure,or a certificate of Workers' Conlpensmion fnsllr:mcc. L11 a certified copy thereol' (Sec. 3800. Lah. C.) dl - .I No. Compimy FOR APPLICANT TO FILL IN BUILDING ❑ BUILDING ADDRESS, gbt ADDRESS Certil'ied copy is herehy Ilunished. 5¢0 I _ S� Y"� �� ! LOCALITY ❑ Certil'ied copy is IIled Willi the 1:0LIl}tlhlllldlllL II1'.I)ictloll CITY / ZIPf/� -7�7 NEAREST department. S In ih VAN WV(? ( _ C 'rl � l 1 ! f _ CROSS ST. Dale _ Applicant SIZE OF LOT NO,OF BLDGS,NOW ON LOT DISTRICT NO. GROUPTYPE PROCESSED BY CONST. CERTII ICAII: 01 EXEMI'11ON I'ROt,'1 ILOT NO. _ ! 1 CUMPENSAIION INSURAN( L TRACT BLOCK MAV MIt�M WAY € 'f NO. (CIRCLE, STATE MAJOR SECOND LOCAL (This section heed not be compleled If the Nor(. imoked ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars Iti 111111 w fuss.) - - -- I � I certify that u. N"c Irr!fornsulcc Of the LL'ork 11,i LLhi,h this OWNER TEL NO. permit is issued. I shall 11-1 employ anyI)erson in Jo\ Inaluler -- --- — -- - -- - So as to become SLIhJCCI to the Workcrs' (.onlpcn.;Itiol: f.;Iws. ADDRESS OCCUPANCY GROUP Date_ - Applicant CITY ZIP NOTIC'I- TO APPLICANT: II'. after making }his ( cmliralc OCCUPANT LOAD of E.venlplion, you should become suhiect 10 the \\orkers' APPLICATIUN FOH - — Compensation provisions oh the Labor Code.you must i'milmith EXIT HARDWARE: comply }villi such pi-m isions or this permit shall he LICenleLl TRAILER U-1E L_] GEOLOGY INSPECTION�_� No Spec.Know(. revoked. ❑ OCCUPANCY INSPECTION�IS Panic Devices ❑ LICENSED CONTRACTORS DECI.ARAIION _ - I hereby affirtn that I Gill licensed Sed ll offer pl'l/1'ISIUnS of linpter SAFETY PERMIT I-1 (LIST ITEMS BELOW) 9(commencing with Section 7000)of Division 3 of the BLIsiness — NO.OF EXITS and Professions Code.and my license is in full force and effect. r PARKING License Number LTL'. ( Ill tiff SPACES REQ'D PROVIDED � t..-�_-_�A_�f-- - .------- --------- -------- Contractor Dme LIMITED TIME USE I _ -- -- DATE DATE I ❑ I all( exempt from the licensing re Cflllremellls as I Gill a FROM: TO: licensed architect or if registered professional erlpineer in - SIZE OF N J.OF INS PECT`OR'S acting In Iny prohCSSrna! C:1pae11N IScCtlon 0�1. Ill:sil ss LXISIINGBLoG. SrORILS I SIGNATURE r all rDI CSSItlI1S CUlel. --- -- --- ----"---------- Lie. or Reg. No. 1XIte PRESENT USE OF BUILDING U cn � S'S e - FINAL APPROVAL 1�.vvi t:c?.s IIONII OWNER-III I11.DI_R I I I ARA110N Nle 0f: xI5IINGBUILDINGS L)N LOT AND USE hereby affirm that I am e\Cn}pt lions IhC Contractor', I ICelhe - - --- --- Law for the lollowing reasiln (Section 70315. Bu,ine,s ilnd _ Professions (ode): NO.PARKING SPACES PROVIDED ❑ 1. as owner of the ImpelO. 11111 d'1 the 1Lork oriel the -"'- ------ -- ----- - __ ___.__----------. StruclurC is not intended or 011121eLl Gn sale (SCclioo 71r1-1. PROPOSED USE OF BUILDING Business and Professions Coda CONSTRUCTION 1-1-NDING /\(if:N( 1 - -- -- herehy affil'nl that there is a ConS(ItICHon IL'1Id111L ueellCt' for the perfornt,nlce ol' the work for which this permit i, issued - ---- -- - ----" (Sec. 3097. Civ. C.). PROPOSED MAX,OCC. Lender's Name APPLICANT IC')i,l,,,'J,,,T/- TEL NO. _ -enders Address ADDRESS /(Mete ADDRESS t certify that I have read this application and SlalC that the 1,2-7 6,Xtor ILA above information Is correct. I agree to comply with all ('�umty PERMIT FEE ordinances and Slate laws relating to huilding constTuclio•I.;Ind herehy authorize representatives of this County to cnler upon IS111ANCEFEE the abovc-mclllioned property for inspection purposrs. -- J- I - - -I^-� L � TOTAL FEE 1 SEER[\�ERSE FOR E?if LANATORI' LANGUAGE .i Signature of Permittee Dale