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HomeMy Public PortalAbout5450 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATIONDECLARATION CE 875 (2 801 MISCELLANEOUS APPLICATION {� CE 876 L J I hereby affirm that t have a certificate of consent to °elf 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 outLD iNG AOGRES S ❑ Certified copy Is hereby furnished iLDINGil LOCALITY ADDRESS SIP- ❑ Certified copy 6 filed with the county building Inspection NEAREST department oc ALiTY Tem le City CROSS .r 16 Date Applicant EARMST Broadway j Rosemead DISTRICT NO GROUP TYPE PROs cROSa .T eoNAT CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DEacwIPTION LOT NO GLOCX MAP .. IGHIN } No If IGIwoL.i STATE MAJOR SECOND LOCAL a No OP DLDas p (This section perm need not be hundred d ll the work involved less) rawcT NOi. oN LOT USE :o NE ° ecul eanomoN• U by the permit is for one hundred dollars ($100) or Tess) use OF SIZE OF LOT EXISTING BLDG a 1 certify that in the performance of the work for which this 0 permit a Issued I shall not employ any person in any manner wNCR USA Petroleum Company U so as to become subject to the Workers' Compensation Laws AIL s O]( OCCUPANCY GROUP 7 LU DDRE.. Date Applicant NOTICE TO APPLICANT If after making this Certificate of IrySanta Monica NoL OCCUPANT LOAD ? 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 USK GEOLOGY INSPECTION deemed revoked No Spec Knowl LICENSED CONTRACTORS DECLARATION oeeul•wncY InSPErnoN Panic Devices ❑ 1 heieby affirm that I am licensed under provisions of Chapter EA19TY PERMIT q (LIST ITEMS eeLOwl NO OF EXITS 9 (c mmencmg with Section 7000)of Division 3 of the Bust ness and Professions Code and my license is In full force and Pw RXINe effect SPACES REG o PROVIDED Lieeflse Number Lic Class LIMITED TIME USE Contractor Date DATA DATE O TD 11 am exempt from the licensing requirements as 1 am a censed architect or a registered professional engineer SIZE OF No OF inveerow a acting In my professional capacity (Section 7051 Bus- &%hone aLDG aro RIES � SIP NATURE mess and Professions Code) ESENT USE OP eUILDina FINAL APPROVAL / Lic or Reg No Date / t7937P One Hour Pntn HOME OWNER BUILDER DECLARATION NO OF EXISTING DmLDiNan ON LOT AND USE �# o o • • ("� s a .I. • . • e I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5 Bust ness and Professions Code) No PARKING SPACES PROVIDED ❑ 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) PwoPOeeo use IF BUILDING None CONSTRUCTION LLNDING 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 1 certify that I have read this application and state that the above information is correct I agree to comply with all County ISSUANCE FEE Ord mantes an tete laws rel in ng tothisbuilding construction TOTAL F [� and hereby Ihonee represe ryes of this County to enter ppan the Ove mention p ty for non purposes SEE REV SE FOR EXPLANATORY AG II/ 12,16/83 atur of t t Date avie arnezr Dir , of Tax sVORKERS'COMPENSATION DECLARATION CE 8754" (2 MISCELLANEOUS APPLICATION I hereby affirm that I hase 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 BUILDIxaism. w00R¢Ea WV Certified copy Is hereby furnishedwLalrva LOCwLITv ❑ wooR¢aa 9008- Broadway, Tem le C3.ty Certified copy Is filed with the county budding Inspection CALITT N¢waenr department Temple Cit cgosa SIT Date Applicant R 0'8 R8 8xE ETT Broadway $ Rosemead DISTRICT NO Dao• TYPQ PRDC¢aRQD ET CR � � CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION I LOT No BLOC. STATE MAJOR $aeono LOCAL OL (This section need not be completed If the work involved NO of L) TqAOT IN.WON LOT M U by the permit Is for one hundred dollars (SI00) or less) I USEOP 0 SIZE OF LOT rA,TING BLDG I certify that m the performance of the work for which this 0 permit B Issued 1 shall not employ any person in any manner 1"IRUSA Petroleum Company U so as to become subject to the Workers Compensation Laws AIL I OCCUPANCY GROUP �� W w REEF y Date Applicant Z NOTICE TO APPLICANT If after making this Certificate of eITT Santa Monica rrioL(2l3) 829-4381) OCCUPANT LOAD 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 O No Spec Knowl ❑ deemed revoked LICENSED CONTRACTORS DECLARATION oceu•wncr INSrecnoN Panic Devices ❑ 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELow) NO OF EXITS 9 (commencing with Section 7000) of Division 3 of the Busi ness and Professions Code and my license Is In full force and PARKING effect SPACES RQD O ED •aoVID License Number - Lic Class LIMITED TIME USE Contractor Date DATA DAT. F-1ro l em exempt from the registered requirements as I am a licensed architect or a reglslered professional engir Der nze of xo of INSPECTOR acting In my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES SIGNATURE (ness and Professions Code) ¢9ENr USE OF BUILDING M Ill Mar —``�r FINAL APPROVAL /1•Q 4 �y Lic or Reg No Date- HOMEOWNER ateHOMEOWNER BUILDER DECLARATION ONO OF EXISTING BUILDINGS S D N LOT ANU I hereby affirm that 1 am exempt from the Contractors : 7936A License Law for the following reason (Section 7031 5 Busl ness and Professions Code) No PARKING • . . . 88 DPAC99 PROVIDED ❑ 1 as owner of the property will do the work and the • e •'• • • • N structure is not Intended or offered for sale (Section ' 7044, Business and Professions Code) 0 7 03- 84 OPOEHD USE OF BUILDING None 1 CONSTRUCTION LLNDING AGLNCY 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 Pwo•oa¢D MAX OCC Lender s Address PERMIT FEE I certify that 1 hose read this gree to con and state that the above information u curet I agree to comely with all County ISSUANCE FEE I ordinances hereby and State laws relating to building C construction TOTAL FEE and hereby a rue representatives of this COUGiy to enter upo the a ve mentioned erty for mspectl purposes SEE REV LRSE FOR EXPLANATORY L GU E 12/A/83 J St re of-P e Date ( Xavier R. Martinezt Dir. of Tax byaffrm COMPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION {� CE 876(11 84) L1 nsure, o affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION metre, or a certilieate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3900,Lab C) Policy No Company FOR APPLICANT TO FILL IN nonweeIS Certified copy is hereby furnished Bu1LDING wD D...9 �l� C. (,�/� � LOCALITY Certified copy Is tiled with the county building inspection ��- Ne AREaT department LOCALITY /c pLG CfT .4-9/ 7PJ cE09 Ge er Date Applicant NEAREST QD.5eC� OI¢rRl a u ry PG PRO !¢D yr CROYfeT /` t C.Mar CERTIFICATE OF EXEMPTION FROM WORKERS' LcaAL N LO COMPENSATION INSURANCE D...RIPTIOT No SLOCN MAP erwT¢ MwroR EC+D LOCAL ND oP eLDa9 No (c,Re L•) ('Chu section need not be completed If the work involved r¢wcr now ON LOT u^sE zoNE SPaeuL CONDITIONS by the permit is for one hundred dollen ($100) or less.) U9K or I certify that m the performance of the work for which this SIZE OF LOT Ex I.TING BLDG J permit Is issued, I shall not employ any person many manner OWNER - so as to become subject to the Workers' Compensation Laws �$'f/CLL O/L G(� MAIL EOCCUPANCY GROUP Date Applicant A D'S IS Q IBO— O T p w NOTICE TO APPLICANT If, after making this Certificate of CITY f��C/.4f 4# noL a e oExemptiOCCUPANT LOAD Compensation you should become subject , the Workers- Ap LICATION FOR EXIT HARDWARE Compensation proviaons of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked TRAILER USE ❑ GEOLOGY INSvecrloN ❑ NO Spec KROWl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am heensed under provisions of Chapter SAFETY PERMIT —] (LIST ITEMS BELOW)9 (commencing with Section 7000) of Dwmon 3 of the Busy NO or EXITS ness and Professions Code,and my license is in full force and effect PARKING SPACES RED D PROVIDBD (= License Number Lie Class LIMITED TIME USE Contractor Date P.rR DATR 1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engineerEOF INEPKCTon S acting m my professional capacity (Section 7051, Bur EXISTING BLDG NOO• SIG TURK 9TORI mess and Professions Code) ��� -/ PRESENT USE OF BUILD IMG S Y/14�ON FINAL APPROVAL Lie or Reg No � Date 0 HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USK I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Bust 9 0 Q 6 A ness and Professions Code) NO PARKING I, as owner of the property, will do PROVIVED do the work and the # • • •I• B $ structure Is not intended or offered for sale (Section 7044,Business and Professions Code) �/ \ • • • • • • • `g CONSTRUCTION LENDING AGENCY r, ROPOSCU USE OF BUILDING v t4/-'lt . 0000-88 I hereby affum that there Is a construction lending agency 5 M ;7S t_ EAJ 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 1 certdy that 1 have read this appb© PERMIT FEE [ion end state that the , above Information is correct 1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to budding construction, and hereby authorize representatives of this Cou ty to enter TOTAL FEE upon the abov ntioned property for mspectio ur SEE REVERSE FOR EXPLANATORY LANGUAGE ure of Plitmittee Date WORKERS COMPENSATION DECLARATION CE l,pere875 M ISCELLANEOUS APPLICATION {� CE 87fi 17 7 84) LJ insure, affirm that I have a s'Compenatesation 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 SS Certified copy is hereby furnished V DU ILDIG n wDowcNaa Lu LouurY ❑ Certified copy is filed with the county building inspection-,. LOCALITY ,g NEAR SST department (:.f cao•E ST Date Applicant cwone eT L w.TR sur No 0 o corvnr re Seep BY CERTIFICATE OF EXEMPTION FROM)&'ORKERS' LEGAL COMPENSATION INSURANCE BE SCRIPT LOT No BLODK Rrw S rM+oP (owcL.1 a corvo Loc wL (This section need not be completed ll the work involvedn or LOGS Srwr¢ nswioR ON LOT USE zone SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or lessen;I TRACT No NoUSEor I certify that in SIZE or LOT EX IS TING BLDG the performance of the work for which this ' o permit is issued, I shall not employ any person in any manner 14 OWNER CO SO as to become subject to the Workers' Compensation Laws Mw IL OCCUPANCY GROUP o Date Applicant �J AA NOTICE TO APPLICANT If, after making this Certificate of-,A CITY CA I noL OCCUPANT LOAD DW- 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 pernut shall be TRAILER USE GEOLOGY IN arcenoN deemed revoked ❑ ❑ No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bust­ swrerY reRMtr ❑ (LUT ITEMS BELOW) No or EXITS ness and Professions Code, and my license is in full force and effect PARK IN aPw O¢E R800 PROVIDED License Number Lic Class LIMITED TIME USE Contractor Date ..1. ..T. I am exempt from the licensing requirements as I am a T. licensed architect or a registered profesaonal engineer SD:E or No or I SP CTOR8 acting in my profenional Capacity (Section 7051, Bus- EXISTING BLDG STORIES mess and Professions Code) — O V rR eS¢nr USE or BUILDING FINAL APPROVAL G Lic or Reg No Date CJ HOME OWNER-BUILDER DECLARATION no or EXISTING BUILDINGS ON LOT AND USE I hereby affirm that 1 am exempt from the Contractor's License Law for the followmg reason (Section 7031 5, Busy ' ness and Professions Code) NO PARKING I, as owner of thePe yro rt , will do the work and the SPACES PROVIDED P structure is not intended or ) 37 111 1 1 A offered for sale (Section 7044,Business and Professions Code ,/�1 CONSTRUCTION LENDING AGENCY V PROPOSED USE or BUILDING aglCO �` I # • • • • 8 8 1 hereby affirm that there is a construction lending agency0�6 t3 1 \ •'. • . • • • (P for the performance of the work for which this permit is Issued(Sec 3097,Cry C) U S Q 7-8 7 Lender's Name Lender's Address PROPOSED MAX OCC I certify that 1 have read this application and state that the PERMIT FEE above information is correct I agree to comply with all County ISSUANCE FEL ordinances and State laws relating to building constriction, and hereby authorizerepres ives of this County to enter TOTAL FEE ,QD u ti ve-menoried p y f inspection purr osea /91 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o ermittee Date i ' WORKERS COMPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION t u CE 875 (]801 FherebyAaffirm 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) Policy No Companl FOR APPLICANT TO FILL IN ❑ Certified copy B hereby furnished mLmwa 0/0 Y ppo LOCALITY AODReae G iT ❑ Certified copy B filed with the county budding inspectionPNEAREST department OOALITY T -��a EM PLE C2 A cRoae aT E/y) Date Applic Int ARMY DISTRICT NO a UP TYPE Pwo •¢D BY cRoae aT MFA2) RLQ �,^ilp �•1 CONST , / CERTIFICATEOF EXEMPTION FROM WORKERS LEGAL V fA iC— V COMPENSATION INSURANCE D¢ac RIP ION LOT No BLOCK MA. HIGHWAY } (CIICLE) STATE MAJOR SECOND LOCAL a No OP BLDG. (This section need not be completed If the work Involved TRACT NOW ON LOT USE ZONE ePHciwL CON TIGNS U by the permit Is for one hundred dollars ($100) or leas) ua¢ of SIZE OF LOT a .,TING BLDG 1 certify that in the performance of the work for which this ^ \/ 0 permit B issued I shall not employ any person m any manner wwER a5n ��(„�'(� JPATZo/�f /1 so as to become subject to the Workers Com p<nsatlon Lawn AIL \/ OCCUPANCY GROUP T/- W wDORMB 6i3L3 KD '�• U y Date Applicant 7-ryyIt �/ �-� NOTICE TO APPLICANT If after making the Certificate of eITf�y /�ICyKT�,q' srioL64,3)P ?-4393 OCCUPANT LOAD z 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 O GEOLOGY INSPKCT20N❑ No Spec Knowl ❑ deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION PBDIC DOVICEa ❑ I hereby affirm that 1 am Imensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO OF EXITS 9 (commencing with Section 7000)of Division 3 of the Bust ness and Professions Code and my license is in full force and Pw wEINa effect SPACES RUG D PRovlo¢o License Number Lie Class LIMITED TIME USE Contractor Date oAr. DAT. TO ❑ 1 ns INSPECTOR e oexempt from the licensing requirements as I am a PwDM licensed architect or a registered professional engineer SIZE OF No oP acting .n my professional capacity (Section 7051 Bus- EXISTING BLDG .TOR.Es a NATUne iness and Professions Code) 11 NLD TO FINAL APPROVAL 68GNT U6H OF BUILDING 14CUR Lie or Reg No Date HOME OWNER BU11 DER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND Ung I hereby affirm that 1 am exempt from the Contractors / 7 a 5 A License Law for the following reason (Section 7031 5 Busi ness and Professions Code) NO PARKINO SPACES PROVIDED ❑ 1 as owner of the property * p petty will do the work and the structure is not Intended or offered for sale (Sectionj • • • • • • •112 7044 Business and Professions Code) PoeeO UBE OF BUILDING F 1449m Oro CONSTRUCTION LLNDING AGENCY /� 0 &03-85 1 hereby affirm that there Is a construLsion lending agency for the performance of the work for which this permit is issued(Sec 3097 Civ C ) Lenders Name PwoPoneD MAX occ Lender's Address PERMIT FEE 1 certify that I have read this application and state that the above information.s correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction TOTAL FEE and ereby th nze representatives of this County to enter upot thea o/e len to d property for inspection urposes SEE REVERSE FOR EXPLANATORY LANGUAGL Sig tureof Permitte �/ WORKERS COMPENSATION DECLARATION E 875 ill awl CE MISCELLANEOUS APPLICATION C 8]5 I hemsun' or affirm Leri that I have a certificateComn of consent to sett COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION unwre or a cerLlicate of Workers Compensation Insurance,or �I a certified copy thereof(Sec 3800 Lab C) Policy Na Company FOR APPLICANT TO FILL IN BUILDIN4 ACORE., Certified copv is herebs tarnished UGORILO6NSSG Ib D _ eeORPWA LOCALITY 1 Certified copy is fded with the LOunp budding mspectn n LOCALITY NEAREST department cfloss ST Date-Applicant NEAfl¢sr C� E� • o1sTfl r N a[o TYr c¢ss¢o eY cfloss ST J D� CDN T CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No BLGCR 1OM1•" srwrE MAJOR SECOND LOCAL No OF OLDGS (Thu section need not be completed If the work involved TRACT NOW oN LOT Ula ZONE9P¢cuL co NO1T1ONs by the permit IS for one hundred dollars IS 100) or less) us[ or 1 SIZE OF LOT [%1l TIN. aLDO - I Certify that m the performance of the work for which this /1 permit a Issued I shall not emplov any person in any manner[ wneR B 1 /y'f✓, - so as to become subject to the Workers Compensation Law AIL OCCUPANCY GROUP = 6 LJ1C,(L LtJW G - 1 DRESS Date 4ppliclnt G = NOTICE TO APPLICANT If after making this Certificate o . G O ru OCCUPANT LOAD - Exemption you should become subject to the Workers Compensation provisions of the Labor Code }ou must forth- APPLICATION FOR EXIT HARDWARE m 1 with Comply with such provatons or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY 1Nv[cnONXX Panic Devices °1 I hereby affirm that I am licensed under provisnonsol Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) ' 1 9 (Lommenciug with Sec'ion 7000) of Division 3 of the Busy NO OF EXITS ness and Professions Code and my License is in lull force and effect 0NG arwc¢s REG G � PRovIG[o o License Number Lic Class LIMITED TIME USE R Contractor Date DAT. GAT. 0 I am exempt from the licensing requirements as I am a m I licensed architect or a registered professional engut_ersize a, INSPECTOR s a actmg m my professional cnpacaN (Section 7051 Bus- EXISTING OLDG 9TOfl 169 IS 1741TU.E mess and Protessions Code) oFINAL APPROVAL PRESENT USE OF BUILDING 8 Lic or Reg No Date a 1 HONE OWNER-BUILDER DECLARATION No Or EXISTING BUILDINGS oN LOT Ano Us¢ "\ ,JJ��"�� � I hereby affirm that I am exempt from the Contractors 0 `k' /, (7�AJfJ-I I['_r�E1^ ';•4'rS 1 License Law for the follow ung reason (Section 7031 5, Busy ness and Professions Code) NO PARKING 'IM.• - - 1, as owner of the property, will do the work and the sr.eEs PROVIDED structure is not intended or offered for sale (Sectio ( 7044,Busmess and Professions Code) CONSTRUCTION LENDING AGENCY a P OrOS[O use OF BUILDING I hereby affirm that there a a construction lending agency .1-S V eld 1 for the performance of the work for which this permit is awed(Sec 3097,Civ C) /".Vol/477 ' Lender s Name rworoEEo MAX occ Lender's Address ( I artily that I have read this application and state that the PERMIT FEE 25.00 above infoanatnon is correct I agree to comply with all County ISSUANCE FEE ordixuances and State laws relqDrig to budding construction and here au :e reptt atives of this County to enter TOTAL FE[ 25 1 I upon t ab men ed .00 TO for Inspect—,purposes EE REVERSE FOR EXPLANATORY LANGUAGE T Clrn�ttrtP n(PrrmrttPe bate