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Home My Public Portal About5526 ROSEMEAD BLVD_Miscellaneous__ WORKERS COMPENSATION a ION DECLARATION CE 875 MISCELLANEOUS APPLICATION {1 CE B]6(11 641 LJ hereby ¢ furnCert that I have a certificate Compen of consent to self re, or n certd.cateofworkers compensation Insurance or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certifwd copy thereof(Sec 3800,Lab C) Policy No Company — FOR APPLICANT TO FI LL IN Boen¢en 2 FiCertified copy Is hereby furnishedsit aO1NG LOCALITYDDRQ88 ❑ Certified copy is filed with the county building inspection LOCALITY NE wR esT department ceoeS er Date—Applicant ARe.r DISTRICT No a OUP IT PE PRO Sa Ev 5.4.AS.,QT Dj �y eoNSr I CERTIFICATE OF EXEMPTION FROM WORKER$' LEGAL ••(/ 1/ COMPENSATION INSURANCE DESCRIPTION LOT No BLOCX IGHWA' STAT¢ MwioR SE co D LocwL No or OLDOS POP (.Incl..) (This section need not be completed If the work involved TRACT NOW ON LOT USE zone SPECIAL CONDITIONS by the permit is for one hundred dollars ($I00) or less.) use or I certify that in the performance of the work for which this I 'zE Or LOT IS I.TING BLDG permit is visited, I shall not employ any person in any manner OWNER so as to become subject to the Workers Compensation LawsI Cc AIL OCCUPANCY GROUP o DRESS Date Applicant w NOTICE TO APPLICANT If, after nuking this Certificate of Ncrry ,`--f- TffoL 417- OCCUPANT LOAD D- Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APP ICATION 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 INSPQcrION Panic Devices I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of DurSwP¢rr PeRNston 3 of the Bust- E] (LIST ITEMS BELOW) NO or EXITS ness and Professions Code,and my license is in full force and effect PARKING REO D D PROVIDED D License Number SPACES Lie Class LIMITED TIME USE Contractor DateDAT• T. 1 am exempt from the licensing requirements as I am a Y. licensed architect or a registered professional engineer sae OFNG or INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG TORIE. SI NATURE mess and Professions Code) FINAL APPROVAL Lie or Reg No Date Reaamr viae or Gu uomG �! HOME OWNER-BUILDER DECLARATION NO or EXISTING BUILDINGSt ;2 1 ,2 Q,7 A ON LOT AND USE v 4 I hereby affirm that I am exempt from the Contractor's i U License Law for the following reason (Section 7031 5, Bust- 1�IV O 0.00-88 ness and Professions Code) NO PARKINS I, as owner of the property, will do the work and the SPACES PROVIDED O G O O`8 8 structure is not intended or offered for sale (Section 7044,Business and Professions Code) i B 12(I 8 A CONSTRUCTION LENDING AGENCY PROPOSED USE Or BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this perm.[ u issucAl§c 3097,Civ C) der s Name PROPOSED MAX OCC Lender's Address PERMIT FEE I certSy that I have read this application and state that the above informations correct I agree to comply with all County ISSUANCE FEE o din aces and State laws relating to building construction, d hereby authorize representatives of this County to enter TOTAL PEE pont Eve-i ntioned property or inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE AIJ Si na ser r ee Date WORKERS'COMPENSATIONDECLARATION CE 875(280) MISCELLANEOUS APPLICATION I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insure or a certificate Ot Workers Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) Policy No Compan) FOR APPLICANT TO FILL IN woowc�a S ❑ Certified copy a hereby furnished IS amLVINGtP�AjG Elwoowlsand F LOCALITY Certified copy Is filed with the county building Inspection NEAREEr department LoewLlTr'T •.� CRoan TIT Date Applicant wwaaT DISTRICT NO GRO v Tv vE Pwo ¢D D CRUBa Er 5 _ coN CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DQec RIPTION LOT No DLocx NAP v lO„WAT } (owuE) n,w,E Nwiow secorvo LOCAL A (Thu section need not be completed J the work involved NO O LOT us¢ ZONE SPECIAL CONDITIONS pp Twwcr now F LOT CL by the permit is for one hundred'dotlars (5100) or Iess) UAE of C� 1 certify that in the Size oP Lor Ex lanrva SLOG (� cc y performance of the work for which this C O permit Is Issued I shall not employ any person in any manner wNER • so as to become subject to the Workers Compensation Laws AIL OCCUPANCY GROUP K Z W Date Applicant DDRE 3 So � ry y NOTICE TO APPLICANT If after making this Certificate of ITvAl NO _ 02 8 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 TRI11LKR USE GEOLOGY INSPECTION Spec KnOWI ❑ deemed revoked O P LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices ❑ 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITE.. BELOW) No DP EXITS 9 (commencing with Section 7000) of Division 3 of the Bust ness and Professions Code and my license Is in full force and PwwxlNo effect SPACES Rev v E= Pwovlvev License Number Lic ClassLIMITED TIME USE Contractor Date DATE DATA ❑ TO I Sm exempt from the licensing requirements as I nm n Iicensed architect or a registered professional engineer SIZE OFNo vF INSPECTOR a acting In my professional capacity (Section 7051 Bus- EXISTING BLDG .-,.RIES SIGNATURE mess and Professions Code) HFINAL APPROVAL EBNT USE OF BUILDING Llc or Reg No Date HOME OWNER BUILDER DECLARATION .N LOT AND N No of HND USE EUILoinaa 1 hereby affirm that [ am exempt from the Contractors /1 License Law for the following reason (Section 7031 5 Bust Ness and Professions Code) NO PARKING SPACES ES PROVIDED ❑ I as owner of the property will do the work and the structure is not intended or offered for sale (Section 0 (�/ 2 3 9 Q 6 A 7044 Business and Professions Code) ROPOSUD USE OF BUILDING I CONSTRUCTION LENDING AGENCY I hereby affirm that there is S construction lending agency /V� A • w a B w S a for the performance of the work for which this permit Is L (Sec 3097 Civ C ) Lender 0606-82 rs Name PwovoaeD MAX Dec Lenders Address PERMIT Pee n' \ I certify that 1 have reed thison and state that the l�//✓/ i� \\ above information a correct 1 agreePee to tG comply with all County ISSUANCE FEE I ordinances and State laws relating to bconstruction TOTAL FEE �\ and hereby authorize representatives County of this County Io enter upon the above n nt oned prop rty for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 1 ?l .60, �, 57/x2 Signature of Permit ermi a t� WORKERS COMPENSATION DECLARATION CE 875 (t 1 841 MISCELLANEOUS APPLICATION {� CE 876 LJ I hereby affirm that I have a of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION more, or a certificate of Workerss Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN euILOINa wDOR6R• ❑ Certified Copy is hereby furnished BUILDING DRESS LOCALITY ❑ Certified copy is filed with the county building inspection LOCALITY r NEAR MST department L` cwosS ST Date-Applicant NEAREST Ia.r r a o PrP¢ Pw ¢D ev CROSS 9T PR CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I Lor No aLOCK STATE MAJOR S¢conD LOCAL `\ P GLOOM (This se icon need not b��teeeee completed if the wort[ Involved TRACT MOMNOOON LOT USE SONE IrECIAL CONOITIO NE by the permit is for on hundred dollars (SI00) or less) USE oP I Certify that in the perfarance of the work for which this SIZE Or Lor Exlenno ¢Loa m permit is issued, I shall not employ any person in any manner vrNER (' �� C�i so as [o become subject to the Workers' Compensation Laws i OCCUPANCY GROUP _ �v Date Applicant oowEee, c7 � t-_ IJt ♦C�_ ^• \ \� w NOTICE TO APPLICANT If, after making this Certificate of CIT � �'(��►•� T woL r 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 C1 No Spec Knowl deemed revoked TRAILER USE GEOLOGY INSPECTION LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 11 - Panic Devices 1 hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (Commencing with Section 7000) of Division 3 of the Bust- NO OF EXITS ness and Professions Code, and my license u in full force and, effect 1.) NI"6 RED PROVIDED aPAcee License Number Lic Class ' LIMITED TIME USE Contractor Date DATB DAT. PRDN 1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engmeer Sof INSPECTOR e STORIES SNwruwe acting in my professional capacity (Section 7051, Bus- E TIr noo mess and Professions Code) Lic or Reg No Dale PRESENT USE or BUILDING FINAL APPROVAL HOME OWNER-BUILDER DECLARATION NO OP ext• G au DINGS ON LOT AND USE I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason (Section 7031 5, Bust, ness and Professions Code) NO PARKING ❑ 1, 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) ;901 114 A CONSTRUCTION LENDING AGENCY PRoro.eD USE of BUILDING 1 hereby affirm that there is a construction lending agency # 9 -.988 for the performance of the work for which this permit Is S , S . . . u� issued(Sec 3097,Civ C) Lender's Name 0 7'1 4-88 PROPOSED MAX OCC Lender's Address IZ 1 Certify that I have read this application and state that the PERMIT Feb above information is correct I agree to comply with all County leauwrree Fee V ordinances a d State laws relating to building Conswction, �JJ and hemb thor representatives of this my to enter TOTAL FEE 0 `0 U tithe ve-me coned property f r inspe urposes C '7 SEE REVERSE FOR E LANATORY LANGUAGE Signature of Ittee Date N'ORhERS'COAIPEN5ATION DECLARATION CE 875 Ill 84) M ISCELLANEOUS APPLICATION {� CE 876 LJ I hereby agifm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure ora certificate of Workers'Compensation Insurance,or a mrt)fified copy thereof(Sec 3800,lab C) Pohc�No Company FOR APPLICANT TO FILL IN AftU0Dw ILD 1NBaaG 552 N • w' L Certified copy t5 hereby furnished BUILDING �i26 u RO' +�tEftD 'f3L }) L.� C( e ' ADDREa5 S •, LOCALITY Certified copy is filed with the county budding inspection NEAREST LOCALITYp department T&m VILE CiTy eA CROSS aT $M.Go50 pfa0104 1't' Date Applicant rvK.REaT ��uDISI cr ry OUP TYPE Pwoc a Y CROaa ISTSC(GM6*P Iv"W ' O CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE OESCR I PTION Lor TIGaL... NaL °RXC'wLsl AT STATE MAJOR SECOND LOCAL NO oP eLOca CIRO (Thu section need not be completed if the work involved rwwcr Now ON LCT USE : rE aPEC1AL co no mono by the permit is for one hundred dollus ($100) or less) USE OF I Certify that in the performance of the work for which this SIZE OF LOT ex..TINU BLDG o permit a issued, 1 shall not employ any person in any manner owmzRnVHLW, cD so as to become subject to the Workers' Compenation Laws MAIL n- OCCUPANCY GROUP o Date Applicant ADORSEE S5`L(p PLKIS S" s(„ w U NOTICE TO APPLICANT If, after making this Certificate of clTr "(/(L. C( nal $'I��aQfP 4'100 OCCUPANT LOAD Exemption, you should become subject to the Norken Compensation provisions of the Labor Code, you must fort APPLICATION FOR EXIT HARDWARE with comply with such provmons or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ NO Spec KnoWl deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commemm�g with Section 7000) of Division 3 of the Busy No PERMIT E] (tier ITEMS Below) No oP EXITS ness and Professions Code,and my license is in full force and effect PARK INS awwcaa REG D E= PwoYIOEO License Number Lie Class LIMITED TIME USE Contractor Date DATA Dw TS PON TO 1 am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer SIZE OFINSPECTOR 8 acting m No OF my professional capacity (Section 7051, Bus- EXISTING BLDG NO F Ian Aru RE mess and Professions Code) FINAL APPROVAL Lie or Reg No Date Pw¢SENT use OF BUILDINGkj HOME OWNER-BUILDER DECLARATION No Ow EXISTING BUILDINGS Nb 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- 13000--0001 5/15/90ness and Professions Code) NO PARKING ❑ 1, as owner of thePe ro rt will do the work and the SPACES PROVIDED 0686 1 AM11:Q. P structure is not intended or offered for ale (Section 7044,Business and Professions Code) PROPOSED USE OF BUILDING t CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency (S(&Jv for the performance of the work for wtuch this permit is issued(Sec 3097,Cry C) �\ O Lenders Name Lender's Address PERMIT FEE PROPOSED MAX occ I Certify that I have read this application and state that the 1 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 REE 2s upon the above-mened property for inspection purposes S, SEE REVERSE FOR EXPLANATORY LANGUAGE Sigisat � /Dglie l I r WORKERS'COMPENSATIONDECLARATION 76M444 87544 (11 64) ).^ M ISCELLANEOUS APPLICATION {� LJ 1 hereby affirm that 1 have a certificateof consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insurer or a certificate of Workers Compensation Insurnnce,or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN EUILDING Z,T'7 SIJ oC Certified copy u hereby furnished v Bu DInG ADDS¢aa LOCALITY waoRusee Certified copy is filed with the county building inspection LOCALITY /y NE wE ESr department �I "11 csoen Sr Date Applicant N8wR RST o DISTRICT NO GROUP TYPE PROCESSQ0 BY V CEA AI sir Q O W CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO Bloc¢ r.RRA •o' (Clwcl.e) SYAYK MAJOR SECOND LOCAL rvo Or el.Dae (Thu sechon need not be completed if the work involved rwwcr Now ON Lor USE zorve nP¢cuL eonDmonS by the permit is for one hundred dollars ($IDD) or less) us or SIZE Or Lor EXISTING BLDG n I certify that in the performance of the work for which this o permit is issued, 1 shall not employ any person many mannery owmzR \ So as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP o AD DRESS �� c Date Applicant r'_ L NOTICE TO APPLICANT If, after making this Certificate of�1 CITY L �„ xoL SI v ) OCCUPANT LOAD O_ Exemption, you should become subject to the Workers' V Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE with comply with such provisions or this permit shall bern wlLeR USE ❑ GEOLOGY IN SPQcnoN ElNo Spec Knowl deemed revoked 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 Busy NO PERMIT E) (LIST ITEMS e¢Low) NO or EXIT$ ness and Professions Code,and my license is in full force and effect PARKING SPACES REQ D PROVIDED License Number Lic Class LIMITED TIME USE Contractor Date ElI am exempt from the licensing requirements as I am a .o licensed architect or a registered professional engineer Size or NO or INSPECTOR $ acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES am ATUR¢ mess and Professions Code) FINAL APPROVAL Lic or Reg No Date PRESENT uae or BUILDINGZf HOME OWNER BUILDER DECLARATION J NO Gr EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the followmg reason (Section 7031 5, Busy 7 <) 5 A nm and Professions Code) NO PARKING El1, as owner of the property, will do the work and the SPACES PROVIDED SSSS 8 8 structure is not intended or offered for sale (Section 7044,Business and Professions Code) �. CONSTRUCTION LENDING AGENCY V PROPOSED USE Or BUILDING I hereby affum that there is a construction lending agency V �7 for the performance of the work for which this permit is issued(Sec 3097,Civ C) f Lender's Name U r`, I S6\ PROPOSED MAX OCC lis' Lender's Address TT F V 1 /` I certify y that 1 have read this application and state that the l/ 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 5 6 upon the above-men toned grope y or mspectson urp s i SEE REVERSE FOR EXPLANATORY LANGUAGE I V Signature of P11 i e D to WORALRS COh1PLNSATION DECLARATION CE 675(11841 44 MISCELLANEOUS APPLICATION {� • CE LI 1 hereby aRmn that 1 have a Certificate of consent to self Invite. OF LOS ANGELES BUILDING AND SAFETY DIVISION aure, or a certificate of Workers'Compensation Inn ,or a Certified Copy thereof(Sec 3500,Lab C) Policy No (ompany FOR APPLICANT TO FILL IN ADDRDI 0 ESS �� 6 ElCettified Copy IS hereby furnished1u ILDING 5�z� 1J ��.Q�Qa� � XX wS Certified copIs Ned with the county building inspection LOCALITY ioD LOCALITY NZAR[1T department XX CROSS Sr Date Applicant NEAREST 01 r no a1{OuS TYPE c[ IED or CROSS ST ('OCLdr-L14 D� /� CONS CERTII KATE OF EXEMPTION PROM WORKERS' LEGAL �7 COMPENSATION INSURANCE DEacwvrlor Lor ro eLocN w• 11Ofl"^• STATE MAIDS s[cono LOCAL No or 1LOG6 weP (c,wa.) by t section Deed not be hundred ed ll the work Orinvolved[am) rwwcr NOW ON LOT uapyorLj SPECIAL CororcioNS by the permit n for one hundred ddlan (5100) or kn.l u1E or uu or Lor [xunpa BLDG 1 Cerltty that in the performance of the work for witch this permit Is issued, I sh dl not employ any person in any manneXX OR— of buildin aW k r LQ EOG c' R+ as to Income subject to the Worker{ Compeasahon Laws, OCCUPANCY GROUP n Date Applicant PDosnS �o r)Cl� r] UI U NOTICE TO APPLICANT If, after making this Certificate of CITY (Q,M �p C( noL'�(�(L{'j 7� OCCUPANT LOAD e Exemption, you should become subject to the Workere o KATION FOR EXIT HARDWARE SPI Compensation provisions of the Labor Code, you must forth �7 with comply with such provisions or this permit shall be YRAU.Ew USE GEOLOGY INSPECTION No Spec Knowl deemed revoked I ICLNSED(ON I RAC IORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices I hereby affimh that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bust- NO PERMIT [LIST ITEMS s1Lor) No or [xirS nen and Professrons Code and my license Is in full force a effeLt )!18111e of business SPACING •EGD P-ovm[o SPwcES 1 hLenm Number — 1 is Class -:R v TL rAccer 'Q 1 S=9= LIMITER TIME USVI � (ontmctor Date eAr. e.T. I am exempt from the licensing requirements u 1 am a rReC nrtni ow a licensed architect or a registered professional engineer SIZE or no or 900,7 't acting m my professional capacity (Section 7051, Bur [xceTlNa .Loo STowIEe I eI N mess and Professions Code) FINAL APPROVAL f� LIc or Reg No — Date PRESENT LIS[ OF BUILDING / Vaca nt NOMI OWNER BUILDER DECI ARATION No or EXISTING BUILDINGS {JJ ON Ler AND USE 1 hereby affirm that I am exempt from the Contractor's L License law for the following reason (Section 7031 5, Busy nen and Profession Code) NO Pww[ING 1, as owner of the properly, will do the work and the SPA CES PROVIDED structure is not intended or offered for oak (Section 7044,Business and Professions Code) (ONSTRU( I ION I ENDING AGENCY PROPOSED LIS[ION BUILDING I hereby affirm that there is a Construction ction lending agency f, ( ATI Ja C e for the performance of the work for which this permit is Ismed(Sac 3097,Cir C) Lender's Name _—_— PROPOSED MAX Dee Lender s Addreu _ j certnfy That I have read this application and state that the PERMIT r[[ 25.00 above information is correct I agree to comply with all County ISSUANCE FEE Ordinances and State laws relating to budding construction, and her horse mprese es of this County to enter TOTAL rEE 25.00 upon t abov f ed p p t form ction purpose. SEE REVERSE FOR EXPLANATORY LANGUAGE XX XX p y g