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Home My Public Portal About5449 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M"4 CEMISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF.LOS ANGELES BUILDING AND SAFETY DMSION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab. C.) Policy No. Company FOR APPLICANTTO FILL IN w..... Certified copy is hereby furnished. ■uILDIMa o LOCALITY ADDRES/� / (p ❑ Certified copy is flied with th8 county bullding inspection NEAREST dePartmant.• LOCALITY CROSS ■T. Date Applicant NEARS■T DISTRICT NO. UP TYPE P USSED ■Y CROs■ ■T. CO CERTIFICATE OF EXEMPTION FROM WORKERS' f LEGAL COMPENSATION INSURANCE DESCRIPTION LOT MO. ■LOCK yAP HIGHWAY No. ?jam/ {clwc Li) ■TATIrMAJOR SECOND LOCAL QQrr� ��,,�� OF BLDG/. 4 ffhis Section need not be COIItppI ted if the wort invotred TRACT MOf. ON LOT USC ZONE ■PECIAL CONDITIONS O by the permit is for one }Ittndred dollars ($100) or leaNO .) MCI U IK ■IZ[ OF LOT E%I/TING ■LDG. I certify that in the performance of the work for which this � permit is Issued, I shall not employ any person In any manner OfNER U so as to become subject to the Workers' Compensation Laws- MAIL D OCCUPANCY GROUP .ADDRX// w Date . Applicant 0- NOTICE TO APPLICANT: If, After making this Certlflcate of CITY C No. ,r ff,� 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 •RAILER USK GEOLOGY IM/PECTIONNO Spec. Know[. deemed revoked. Q. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic DBVIC95 I hereby affirm that I am Licensed under provisions of Chapter SAFETY rKRMIT L t 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license L Ln full force and' PARKING effect. /TACE■ Ra Q'D PROVID[D LL��JJ L16, Number Lic.Class ' LIMITED TIME USE CC ctor Date DAT■ PATS PROMt TO. 4 am exempt from the Ucensing requirements as I am ■ licensed architect or 'a registered professional engineer SIZE oil No. OF INSPECTOR S acting In my professional capacity (Section-7051, Bus- ExunNa BLDG. ■TORY■ ■rawwruRE iness and Professions Code). PRESENT USE OIF fuILDINa FINAL APPROVAL � 7 Lic,or Rag.No. Date HOME OWNER-BUILDER DECLARATION NO. OF [%uTING BUILDINGS 2 6 �,3 A On LOT AND UIS I hereby affirm that, I am exempt from the Contractor's - 88 License Law for the following reason (Section 7031.5, Buss- nes and Profeasions Code)_: NO. PARKING SPACES'PROVIDED • O 0,0 O O O DI, as owner of the property, will do the work and the ' , ' ' ' structure is not intended or offered for We (Sectbn 0'9.'2'2—8 2 7044,Business and Professions Code). PROPO/[D USK OF ISUILDING CONSTRUCTION LENDING AGENCY J I hereby affirm that there is a construction lending agency L for the performance of the work for which this permit Is lasued (Sec. 3097,CW.C.). Name Lender's PROPOSED MAX. OCC. ' Lender's Address PERMIT FER I certify that I have read this application and state that the above information is correct.I agree to comply with,all County ISSUANCE FaE ordinances and State lawn relating to building construction, �. and hereby.authorise rep ntatives of this Cduntv to enter TOTAL PEE u th a In t property r tnspectlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Q/G � — Slgnature o Permittee Date WORKERS'COMPENSATION DECLARATION CE 876(2-80) MISCELLANEOUS. APPLICATION I hereby affirm that I have a certincafe of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFE'T'Y DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800, Lab.C.) Pollcy No Company- FOR APPLICANT TO FILL IN ■u.LDING ADD RK// ❑ Certified copy is hereby f."hed. UILDINGLOCALITY AD DaK■■ cs7111 ❑ Certified copy is filed with the county building inspectionItj NKAR■■T LOCALITY LO department. ciao/■ ■4. Date Applicant- ARK■T QISTRICT N0. ttQUP TY K CONST. C SSKD BY COR ■T.' CERTIFfCATE OF EXEMPTION FROM WORKERS' LKGAL COMPENSATION INSURANCE DK/CRIT TION LOT NO. I.L.C. MAP IOM■AY no. (C IRCLti ■TATs MAJOR /[GOND LOCAL //��r--�� L NO. OF SLOG/. /''� (This section need not be completed if the work. involved TRACT NOr ON LOT USK ZONA: ■PKCIAL COryDITION■ }( by the permit is fot one.hundred dollars ($100) of ler.) 8 USK QF _ 4IZK OF LOT NXI/TING SLOG. �. fr I certify that In the performance of the Work for which this ' 0 permit Wlssued, I shall not employ any person in ahy manner rnK so as to become subject to the Workers' Comperuatlon Laws.- IL OCCUPANCY G90UP W DJtt/■ Date_ Applicant 05 NOTICE TO APPLICANT: If, after making this Certificate of Tr. ! rTioL OCCUPANT LOAD ? Exemption, you should become subject to the Workers' Oomperisation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with.comply with such provisions or this permit shall be TRAILKR uiK GKOLOGY IN■rRCT10N NO Spec. KnOWI. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCLfRANCY IH/rKCTION Panic Devices EY I hereby affirm that I em llcerued under provisions of Chapter SAFKTY rKRUrr 1 (LIST ITKYS ■KLOV) NO. OF KXITS 9 ((commencing with Section 7000).of Division 3 of the Busi- ness and Professions Code, and my license Is In full force and ►wRICING. effect. RKQ'D ■PACK■ rROVIDKD S License Number Lic.Clau LIMITED TIME USE Contractor Date DAT/ DAT■ r Rotel To. ❑ 1 am exempt from the licensing requirements as I am e llcanterchitect or ■ registered professional engineer /IzK F F ON0. OIN GN TOR'■ (l a acting in my profe/aional capacity (Sectlon '7051, Bus- KXI/TING ■LOG. ■TORI[/ ■IONATUR� inose and Professions Code). RKSRNT USK Oh' SUILDING FINAL APPROVAL / Lic.or Reg.No.� Date HOME OWNER-BUILDER DECLARATION NO.of AND UNG ■uILDING■ ON LOT AND U/K I hereby affirm that I am exempt from the Contractor's ;9,3 4 3,7 A License i.aw for the following reason (Section'7031.5, Busi- ness and Professions Code): NO.PARKING # • O O O 8 8 SPAcK/ rROVIDKD ❑ I, as owner of the property, will do the work and the structure is not Intended or offered for sale (Section o o I e o 0 0;o 7044, Business and Professions Code). L4eRoPO/KD U/K of ■UILDING 0 8 1 4—8 4 CONSTRUCTION LENDING AGENCY I hereby affirm .that there Is a eonatruetion lending agency for the performance of the work for vrhlch this permit is Issued(Sec. 3097,Civ.C.). Lender's Names rROrO■KD YAJr. OCC. •. Lender's Address rKRMIT PHE I certify that I have reed thi} application and state that the above information is correct. I agree to comply with all County 15BUANCK FKE ordinances and State laws relating to bulldlnk construction, TOTAL FEE and hereby authorize representativps Of this County to enter up ❑ the ab ntlon r arty for inspect n pure SEE REVERSE FOR EXPLANATORY LANGUAGE i:nature of Date WORK ERS' COMPENSATION DECLARATION 2°" IPJeo MISGr~LLArvtVU---) HrrLIL.HI 1v>tti I hero' affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND'SAFETY DIVISION 11= I#c_ ifiaie of Workers'Compermtion Insurance,or a ctrd td-Llopy thereof (Sec. 38M Lab. C) Policy No. Company FOR APPUCANT TO FILL IN Rf1LDINR: U. r BADDRES h ADDRESS Ctrtificd copy is hereby furnished. V LOCALrry Ctrtlfied copy is filed with the county building inspection ZJP department NCRos.�ar. Date Applicant aIZE OF1.01 NO.OF BLDGa.NOW ON LOT DRrrR r Or+2 asoUP 1 T re m BY CERTIFICATE OF EXEMPTION FROM,WORKERS' TRACT LOT NO. f6d{ CO�41`ENSATION INSURANC) b.Ar OGG No, (ORE[) STATE MAJOR 61CCOND LOCAL (Tills section need not be completed If the work Involved AgaESWR MAP BOOK PAGE PARCI2 USE ZONE SF[C AL CONDmoNI b� >rhe permit Is for one hundred dollars ($100) or leas.) I certify that in the performance of the worst for which this pro art ;li NEPI TEL No permit is issued,.I shall not employ arty rson in arry mower so as tq'become subject to the Worters�Compcnsatlon Laws ADDS OCCUPANCY GROUP Date Applicant _ ZIP '�O�TCE TO APPLICANT: If, after making this Certificate OCCUPANT LOAD bi Exeinptioa you should become.subject to the Workers' APPLICATION FOR Compensation provisions of the Labor Code,yon must forthwith EYff HAADWAlIE: ;comply with such provisions or this permit shall be deemed TRAIIIR uea❑ GEX LOGY INSPECTION❑ NO SRecKnowl ❑ revoked LICENSED CONTRACTORS DECLARATION occuPANcv INSPEcTtoN❑ Panic Devicea ❑ I hereby affirm that l am licensed under provisions of Chapter &mwry PEnmrr❑ (usT rrEMS eELow) 9(commencing with Section 7000)of Division 3 of the Business "1O OF ETT' and Professions Code,and my license is in full force and effect MREQ'D PRQVIDED License Number Lic Class Caatr�ctor Date UMITED TIME USE .-❑' ,. DATE DATE I am exempt from the llcensing requirements as I sun a FROsb TO: licensed architect or a registered professional engineer acting w my professional capacity(Suction 7051,Business a'� �� "" "• Pru RE and femons Code). Llc or Reg. No. Date PRESENT LME of euiLDe+Q RNAALLjA'PPROVAL .�-o HOME OWNER-BUILDER DECLARATION NO.OFoumNGeuiLDrNos I - ON LOT AND uSE •�`I h4neby affirm thit I am exempt from the Contractor's License -Law for the following reason (Section 70315, Business and O Ffrpfesaions Code): NO.PARKING 1 El I. PROVIDED O I ,as owner of the property, do the work and structure is not intended or offered for sale(Section 7th SPACES PROPOSED USE OF BUILDRNG Buamesa and Professions Code). _ CONSTRUCTION LENDING AGENCY I Hereby affirm that there is a construction leading agency for tM performance of the work for which this permit Is issued (Sec 3097, CIv. C.). PROQosrD MAx.OCC_ er's Name A.PPuc.ANT(PRI T) TEL NO. Lender's Address ADDRrOS I certify that I have read this application and state that the ' above information is correct,,I agree to comply with all County P"mu F[[ brdinanca and State laws relating to building construction,and hereby authorim representatives of this County to enter upon ISSU NCE FEa the above-mentioned property for inspection purposes. TOTAL F[[ g SEE REVERSE FOR EXPLANATORY LANGUAGE oro o ttee Date WORKER ,,S' DECLARATION 76M4" 875 (1164) cM ISCELLANEOUS APPLICATION CE 876 l� I l0reby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION h.sure, or ■ certificate of Workers Compensation Insurance,or n certified copy thereof(Sec. 3800,Lab.C.). Policy Na _Company FOR APPLICANT TO FILL IN ■ADuILDIIS H 9 DR[■■ Certified copy is hereby furnished. BUILDING �� t,(p LOCALff XX ADDRESS F] Certified copy is filed with the county bullding inspection LOCALITY NEARS■T department. Xx CROSS ST. Dale _Applicant NEAREST DI■TRI N G UP TYPE ESS[D By CROSS ST. , 17Y CONST. CERTIFICATE Of EXEMPTION FROM WORKERS' LEGAL !/ COMPENSATION INSURANCE DESCRIFT ION LAT NO. ■LOCK NAP HMI—AT ND. (clwcL■) STATE MAJOR SECOND LOCAL RO. OF ■LDGS. (This section need no( be Com feted if the Rork Involved TRACT NOW ON LOT USE ION[ ■P[CIAL CONDITIONS by the permit Is for one hundred dollar (SI00) or lest) U■E Or �j.- SIZE OF LOT ....TING BLDG. b 1 certify that In the performance of the work for which this permit Is Issued, I shall not employ any person in any manne3Lg OWNER Of building Lpq c� c� GI as In become giNect to the Workers Compensation Laws- MAIL OCCUPANCY GROUP ADDRESSr- late----- Applicant 3 LUI TEL. OCCUPANT LOAD o NOTICE TO APPLICANT: jr, after making this Certificate of CITY NO. -UD 6 -�2dM . Exemption, you should become subject to the Workers = Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed rn•okcd. ❑ Panic Devices LICLNSE D(1ONTRACiTORS DECLARATION occuPANCY INSPECTION I hereby affirm that 1 am licensed underpprovisions of Chapter SAFETY P[RMrT ❑ (LIST rrEMS ■ELow) 9 (commencing with Section 7000) of Dlvlsion 3 of the Buss NO. OF EXITS nets and Professions Code, and my lkense is In full force" effect. Name Of business PARKING SPACES REq'D PROVIDED License Number Lic. (lass I C-4'4A LIMITED TIME USE (ontrnclor._— — Date DAT■ DAT■ ElI am exempt from thio licensing requirements as 1 am a PROM TDI limned architect or a registered professional engineer SIZE OF ST of IN SIGN TOR'■ acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STl SIGNATURE Ines:and Profeuions Code). �ipklpt r FINAL APPROVALI.Ic.or Reg. No.__._——__ Date PR Ef[NT USE OF BUILDING HOMEOWNER-BUILDER DECLARATION No. Orr wan uN BUILDINGS ON LOT S 1 hereby affirm that I am exempt from the Contractor's Licelrsc I.aw for the following rens<)n (Section 70315, 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). CONSIRUCHON LENDING AGENCY FROPDS[D USE OF BUILDING EPQZTS AQ I llereb)• affirm that there Is a construction lending agency B^ � for the performance of the work for which this permit is imed(Sec. 3097,Civ.C.). Lender's Name ——_— PROPOSED MAX.'OCC. Lender's Address——__ I certify that 1 have read this application and state that the PERMIT OrEE 25 . 00 above fnfurmntkln is cllrrect. I agree to comply with all County IsaUAN�-E FEE mdlnances and State laws relating to buildi cD clion, end hereby authorize representatives of this Co to enter TOTAL FE[ 25 .00 upon the above-mentloned propert for Insp tl purposes r SEE REVERSE FOR EXPLANATORY LANGUAGE XX