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Home My Public Portal About5522-5524 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 78M444 /7 CE 878 (280) MISCELLANEOUS APPLICATION �IUI Iher y affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION msur or a certificate of Workers Compensation Insurance or a cer fled copy thereof(Sec 3800 Lvb C ) Policy No Company FOR APPLICANT TO FILL IN BUILDING ❑ Certified ied copy hereby furnished BU ILOIN6 ❑ DOREea S _ LJ LOCALITY copy is filed with the county budding inspection department LOCALITY NEAREST oaa eT Date Applicant I NEAR H ST DISTRICT NO GROUP TYPE PROC •HD�BY CROSS 6T —6Q /}�(�L � � (� ri CONST • / CERTIFICATE OF EXEMPTION FROMWORKERS' LEGA / a _•!— COMPENSATION INSURANCE DESCRIPTION LOT NO BLDDx MA IDNwA (Thu section need not be completed if the work involved H10O 1=Iw===I STATE MAJOR SECOND LOCAL > NO OF LOT USE ZONE SPECIAL CONDITIONS O TRACT NOW ON LOT by the permit s for one hundred do011n (5100) or less) USE OF on 1 candy that to the performance of the work for which this //��SIZE OF LOT 9 "TING BLDG cc permit Is Issued, I shell not employ any person In any manner WNQN RM a.. O so as to become subject to the Workers Compensatmn Lawe MAIL ^ – OCCUPANCY GROUP B,'j. U DDREEa 1'I Q,F'If LU Date Applicant p Co, NOTICE TO APPLICANT If after making this Certificate of STY NOL_?S5, aQ ��olg OCCUPANT LOAD Z Exemption you should become subaect 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 revoked ❑ p ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) NO OF EXITS a 9 (commencing with Section 7000) of Division 3 of the Bust ❑ ness and Professions Code and my license Is in full force and PwwxING effect EPACCO REG D E= PROVIOQD License Number Lm Class LIMITED TIME USE Contractor Date DAT. DAT. ❑ TO II em exempt from the licensing requirements as I am a mended architect or a registered professional engineer SIZE OF NO OF INSPECTOR a acting In my professional capacity (Section 7051 Bus- xunrvo BLDG IroBIKE SIGNATURE mess and Professions Code) eeenr Uae OP BUILoirvc FINAL APPROVAL Lic or Reg No Date HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor a License Law for the followmg reason (Section 7031 5 Bust '�4 1 Q 7 A ness and Professions Code) NO PARKINS IPA 9E PROVIDED ❑ 1, as owner of the property will do the work and the #�•�� 8 s structure Is not Intended or offered for sale (Section , 7044, Business and Professions Code) ROP06E0 U6E OP BUILDING � s'. � . . . 2 CONSTRUCTION LENDING AGENCY 0�� O1 -82_8 2 1 hereby affirm that there Is a construction lending agency WQI, N �'!1 for the performance of the work for which this permit is issued(Sec 3097 Civ C) arc Co 04ArKE JrJ-Q Lender s Nam PROPOSED MAX Dec Lender a Address PERMIT FEE I certify that I have read this application and state that the above information is correct 1 agree to comply with all County ISSUANCE FEE ordinances plarrIt, Slate laws relating tp buddm o)istruction, Tor AL FEE on here Ihonz rrep s I v of ly to enter on tt ov<menrio d 0 f It porpyies SEE rE2RSE FOR EXPLANATORY LANGUAGE nalu ( ermittee Date WORKERS'COMPENSATIONDECLARATION - 76 876 CE 875 (11 94) M ISCELLANEOUS APPLICATION {� LJ 1 hereby affirm that I have a certificate of consent nc ser 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 Na Company FOR APPLICANT TO FILL IN auILD Ino C.5� — D wo ow enn<J Certified copy is hereby furnished BUlw Inc �g255�a PSL RESS Certified copy ss filed with the county budADDLocwurr ding inspection LOCALITY NEAREST department Cw099 ST Date Applicant Naw R¢aT BRAY D w awouP Tire sa D BY Cwaaw all D Conor n CERTIFICATE OF EXEMPTION FROM WORKERS' v L6awL COMPENSATION INSURANCE DEScwlPnory Lar no ¢LOCK MAP ISNww no (cl cL.�rvo ow RLOas STATE MAJOR a ORD LOCAL cpU,,N�.N'. (This section need not be completed d the work involved rwwcr �1llVN)' VIEW Row DR Lor � tie¢ zone nPEcuL conoinowa by the permit is for one hundred dollars ($100) or less) SIZE OF LOTI U6¢ OP I certify that in the performance of the work for which this 'b KBO Ewanrvo ELOarj(t6A15 ST✓t ' permit is issued, I shall not employ any person in my manner OWNER FUWK CIIG�IJ Ea SO at to become subject to the Workers Compensation Laws /� AMAIL OCCUPANCY GROUP Date Applicantrr ADORE.. P-yh OOX I9b` U ` ( w NOTICE TO APPLICANT If, after making this Certificate of CITY F .�- M• 001t no Q A4A-81t33' 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 deemed USE ❑ GEOLOGY INar¢cnoR ❑ No Spec Knowl deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El I hereby affvm that I am licensed under provisions of Chapter ,ww ETr .¢KNIT❑ (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 . 1 / � �'.R- - effect ODC-14 N(, OP (I"lMM�9�.�q-t- PARKING SPACES REO D D PROVIO Ea D License Number Lic Class t.D� JSK &J A(LTITIGN LIMITED TIME USE Contractor Date DwrX D.rX I am exempt from the licensing requirements as I am a rD Licensed architect or a registered professional engineer SIZE OF ND or INaPEcrow a acting in my professional capacity (Section 7051, Bus- EXISTING SLOG STORIES Sionwru E mess and Professions Code) FINAL APPROVAL Lie or Reg No Date PRESENT tine or BUILDING HOME OWNER-BUILDER DECLARATION No OF EXISTING BUILDINGS :u ON LOT AND USE 1 hereby affirm that I am exempt from the Contractor's ��T�t License Law for the following reason (Section 7031 5, Bust ness and Professions Code) NO PARKING 3M7 93 1, as owner of thePe Y. ro rt will do the work and the SPACES PROVID¢O 1 ITIS P structure to not intended or offered for ale (Section 7044,Business and Professions Code) TOTAL 810. 50 PROPOSED USE Or BUILDING 80.50 CONSTRUCTION LENDING AGENCY 1 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 t�i'li1(,_(�001 IV29/&, Lender's Address VVIIWWVV WV 11G6//CC V I certifythat 1 have read this a hmtion and state that the PERMIT FEE PP '5. 7E58 1 Al19:31 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 County to enter TOTAL FEE upon the Bove-n entioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE of Permitee fDate