The URL can be used to link to this page

Home My Public Portal About5405 ROSEMEAD BLVD_Miscellaneous__ 1778 WORKERS'COMPENSATION DECLARATION CE 8454(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a.ce7111cate or workers'Compensation Insurance,of , POV N B�IIeLC_,TCompany FOR APPLICANT TO FILL IN BUILDING LD �• J °[7rii`dn Fire. iins�uranc e. o. ADDRESS J @f Certified copy is hereby furnished. S.ee: letter 'BUILDING - LOCALITYADDRESS ,� Certified c Is�1edw th count build' I ct n NEAREST depanrtmen. zzier 'K a.uravnts gh 'I. nc. LOCALITY TenIP1e City 9(780 CROSS ST. Date�y/93 Applican}tNEAREST DISTRICT NO. G UP TYPE P,R ESSED BY t1,ss- "e' a.ryy CROSS ST. �O CONST. CERTIFICATE OF EXEMPTION FR WORKERS' LEGAL ir COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SE;CO ND LOCAL n/a NO. OF BLDGS. NO. (CIRCLE( (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 OF I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. C>:o permit is issued, I shall not employ any person in any manner OWNER d� Uci Edi Qy so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADDRE.SS1025 .S-. -Fremont Ave.. -Alhambra 9_1803 -� (- Date w Applicant CU TEL'. . NOTICE TO APPLICANT: If, after making this Certificate of CITYAlhambra. 9180.3 NO, 8:18-457-2945 OCCUPANT LOAD N Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: z Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE El GEOLOGY INSPECTION❑ No Spec. Knowl. ❑ deemed revoked. n'/a,ICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El 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 r Q �Tsl QSJ a PARKING effect. SPACES REQ'D PROVIDED C License Number Lia Class Sizzler Restaurant .#1778 LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FRDM. T0. licensed architect or a registered professional engineer SIZE OF NO. OF INSPE CTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL A PP IR CO PRESENT USE OF BUILDING - .. / ,7 Lie.or Reg.No. Date c n/a HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS j 2' L �`�� I r 8 _il CUI :� lri •_ ON LOT AND USE _ �� I hereby affirm that I am exempt from the Contractor's 782 1 I�i'� !y t License Law for the following reason (Section.7031.5, Busi- ness and Professions Code): NO. PARKING 0 I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). PROPOSED USE OF BUILDING Restaurant n/a 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. Lender's Address PERMIT FEE 5 DO 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 DO upon t above Ment' ned roperr inspection purposes. ISizz R an�s t 1. ��g/93 SEE REVERSE FOR EXPLANATORY LANGUAGE A Date WORKERS'COMPENSATION DECLARATION 7 CE 85 (11-84) MISCELLANEOUS APPLICATION .� CE 875 I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab.C.). BUILDING ♦5— Policy No. Company — FOR APPLICANT TO FILL IN ADDRESS Certified copy is hereby furnished. J BUILDING ADDRESw� /� �� LOCALITY Certified copy is filed with the county building inspection LOCALITY n�G^ 917& NEAREST department-. f /� VV CROSS ST. Date Applicant NEAREST //�� DISTRICT SIO. GFF UP TYPE PR ESSED BY CROSS ST. /T i 6)Y OI ICONST., / CERTIFICATE'OF EXEMPTION FROM WORKERS' LEGAL /V �( Y COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP `J /HIGHWAY NO. /-! /� (CIRCLE) STATE MAJOR S OND LOCAL NO. OF BLOGS. (This Section need not be completed if the work involved TRACT NOW ON LOT U E ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of /y�\ SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this ,��,// �-d permit is issued, I shall not employ any person in any manner- OWNER f1�1A� r/"//L4.C� o so as to become subject to the Workers' Compensation Laws. MAILn h OCCUPANCY GROUP ADDRESS 0��7OC �� C~3 Date Applicant C,.J NOTICE TO APPLICANT: If, after making this Certificate of CITY .4 je,� 9&/� NOL �� S��.J�3�/ OCCUPANT LOAD � V5 Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Z 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. 0 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 effect. PARKING SPACES REO'D PROVIDED License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPj CTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES sI NATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lie.or Reg.No. Date ( f HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS f 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 I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING , I hereby affirm that there is a construction lending agency 2 6 740'A for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). # o o;® 9•8 8 Lender's Name PROPOSED MAX. OCC. O 0,0 O.010 O Z Lender's Address PERMIT FEE I certify that I have read this application and state that the3,26-87; 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 upon the above-mentioned prokerty for inspection pu poses ////�`�A�//■ *Datej SEE REVERSE FOR EXPLANATORY LANGUAGE Signature ofPer ittee