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Home My Public Portal About5528-30 ROSEMEAD BLVD_Miscellaneous__ � r WORKERS'COMPENSATI ON DECLARATION 76M444 • CE 676(11 E4) M ISCELLANEOUS APPLICATION {� I hereby atTA that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION lJ 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 ADDRESS Certified copy a hereby furnishedwuILDa•S id RAINa X p� D. ! LOCALITY eoR Certified copy a filed with the county budding inspection LOCALITY NEAREST department ❑ CR 035 ST Dale Applicant ewwear pw��Y� ))TRIC xQ/ LIP TYPE P a•ED By CRA RT I�L{{77 v ��I CONST 1/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL G /CC (/ COMPENSATION INSURANCE DRnc RIP ION LOT No BACK www.. wG� jmw u•) STATE MAJOR SECOND LOCAL rvo or BLDGE (Thu section need not be completed if the work involved TRACT Naw ON LOT U59 ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) Ute or - SIZE or Lor E%..TING BLDG 1 artily that in the performance of the work for which this o permit a awed, I shall not employ any person many manner Io so as to become subject to the Workers' Compensation o Laws AIL OCCUPANCY GROUP Date Applicant DR S . p W NOTICE TO APPLICANT If, after making this Certificate of ITY No TQL OCCUPANT LOAD 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 TRAILER USK GEOLOGY INSPECTION deemed revoked ❑ ❑ No Spec Knowl LICENSED CONTRACTORS DECLARATION occurwxcY 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 Bust, NO Or EXIT2 mess and Professions Code,and my license a in Hill force and effect PARKING RQDD PROVIDED erwcES License Number Lic CLus — 14C. LIMITED TIME USE Contractor Date Ow*• DAT. •wow I am exempt from the licensingeas I am a licensed architect or a registered professional engineer SIZE ow No or ' IrvSPt croR'S acting m my professional Capacity (Section 7051, Bus- EXISTING BLOa Q�' �p STORIES SI ATURE mess and Professions Code) RESENT USE or BUILDING FINAL APPROVAL // _ Lic or Reg No Date /Q HOME OWNER-BUILDER DECLARATION NO or UX STING BUILDINGS N0 FE ON LOT AND USE 1 hereby affum that I am exempt from the Contractor's - License Law for the folloxmg reason (Section 7031 5, Bust, ness and Professions Code) No PARKING U 6 ULLI(I']llLil !/1 t�7. 1, as owner of the property, will do the work and the erwceS PROVIDED ' 1 _'L structure a not intended or offered for sale (Section D .� 1 PM %Ou 7044,Business and Professions Code) PR)rose) USE or BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit a awed(Sec 3097,Civ C) Lender's Name PROPOSED MAX Dec Lender's Address s.:j PERMIT FEE I certify that 1 have read this application and state that the above information Is Correct 1 agree to Comply with all County ISSUANCE FEE ordinances and State laws relating to budding construction, �O and hereby authorize represents fles of this County to enter TOTAL FEE upon the hove-menti) prope b for inspection purposes SEL REVERSE FOR EXPLANATORY LANGUAGE igna Per t Date WOIR(LRS COMPENSATION DECLARATION 76M444 ,,,,( • CE 675 (,80) MISCELLANEOUS Ar, PLICATION 1 hereby a cert that I have a cLComp n of consent to ser COUNTY OF LOS ANGELES WILDING AND SAFETY DIVISION ' insure ol�a certificate of Workers Compensation InsuranLL or a certified copy thereof(Sec 3800 Lib C) Policy No Company FOR APPLICANT TO FILL IN DUILOI NB j "rDRE99 .JO ❑ Certified copy B hereby furnished • LOINo ❑ DDws9S 5530 N. Rosemead Blvd. ""'r 7`, dC - Certified copy B filed with the county budding inspection NHAREBT department LOCALITY <R09E ST Date ApplicantNEAREST DISTRICT No GROUP Tr PE woc SseD�r CROSS 9T So O CONN. / CERTII KATE OF EXEMPTION I ROM WORKERS LEGAL p �/ COMPENSATION INSURANCE DHBCRIPTION LOT NO e3Z O LOCK M.r O/ 1CGp 9TATH MAJOR SECOND LOCAL } (This section need not be completed d the work involved TRACT xow OF Lor S USE ZONE 91CCIAL CONDITIONS a0 by the permit is for one hundred dollars (3100) or less) U USE TI C-3 SIZE OF LOT H%IBTING BLDG ` LJ I certify that In the ll note employ of the work for which this 0 cc permit ¢ issued I shall not employ any person m any manner OWNER of aUtldtn F so as to become subject to the Workers Compensation Lows MAIL OCCUPANCY GROUP 4 U ADDRESS 1630 So. Myrtle Ave. a Date Applicant Vj TEL NOTICE TO APPLICANT If after making this Certlflca4, of CITY o is NO 285-3175 OCCUPANT LOAD Z Exemption you should become subject to the Workers Compensation proslsions of the Labor Code you must forth APPLICATION FOR EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER USE I] GEOLOGY INSPccrroN O NO Spec Know) ❑ deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPHCTION RX Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO OR EXITS 9 (commencing with Section 7000) of Dnaion 3 of the Bust ness and Professions Code, and my license is in full force and Applicant's NaMe - Don Reinders PARKING r� effectSr AC Ha REo o rw OVIDCD u License Number LIc Class - 578 N. Heathdale Ave. Covina, Ca. 91722 LIMITED TIME USE Cont Tactor Date RATS RATA ❑ 1 am exempt from the licensing requirements as 1 am a Phone - 332-9751 licensed architect or a registered professional engmecr SIZE or No OF InarecroR S acting in my professional capacn) (Section 7051 Bus- EXISTING BLDG aTONiEs SIGNATURE iness and Professions Code) FINAL APPROVAL P BENT USE OF BUILDING empty Llc or Reg No Date V HOME OWNER BUILDER DECLARATION NO E%i9 TING DuiLOINas ON LOT Ano use I hereby affirm that 1 am exempt from the ContraLtor s License Law for the following reason (Section 7031 5 Bust B 3 2 2 0 A ness and Professions Code) NO rARK1NG O 1, as owner of the property well do the wSPACES PROVIDED work and the # • • It • 40 structure is not Intended or offered for sale (SLetlon • R R R R R Arg 7044 Busmess and Professions Code) roacD USE or BUILDING brake shop 1126-80 CONSTRUCTION LI NDING AGI NCY � I hereby affirm that then. Is a constrti.tmn 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 1 base read this application and state that the above information B correct I agree to Lompl) with all Count) ISSUANCE FEE ordinances and StatL laws relating to budding construLttun TOTAL PEE and hereby authorize representatrs Ls of this County to enter up o a abovem/$-{,,toned prop{��/iy for inspection purposes SEF REVERS• F04R EXP ANATORY LANGUAGL ' 11-20-80 elure ofillirroluittee Date WORKERS CUMYhNSAtnIN uet.LAKA IVN 20-0083DPW12/00 MI�L.LLL/�l�1GV1J.7 F1rrL,l�.t'1a .v,. L hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ( •insum or a certificate of Wdtkers'Compensation Insurance,or h i a Certified copy thereof (Sed 3800, Lab.C) ' Policy, Norl73U2 C0mpgny f.�A F6yjy FOR APPLICANT TO FILL IN ��B I�y �"•+-~— r nUILDI (ID es I �rp'�' Certified copy Is hereby furnished. a[ �,�. L3 Certified copy is filed with the county building Inspection crrr NEAR®T I department 'riwOft Ct Q/1ijr0 „� Date '�. Applicant le C ,1SIZE OF LOT No OF at nrq Now ON LOT DI9'rRIC'r No GROUPTYPE PROCaaseo BY � CEUMC4TE OF EXEMPTIO ROM WORKERS CCNar O COMPENSATION INSURANCE TRACT BLOCK LOT NO ro „ V IcuevE STATE MAJOR SECOND LOCAL (This section need not be completed if the work Involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONpirtONS ad by the permit m for one hundred dollars ($100) or less.) q L certify that in the performance of the work for which thisRi er C1411J TEL No Permit is Issued. I shall not employ any person lin any manner va{CB L!I✓Or "M HN m 1 so as to become subject to the Workers Compensation Laws ADDRESS OCCUPANCY GROUP Date Applicant un G ZIP 4(0 NOTICE TO APPLICANT If ager making this Certificate A-/eadea- of Exemption you should become subject to the Workers APPLICATION FOR OCCUPANT LOAD Compensation provisions of the Labor Code.you must forthwith EXIT HARDWARE comply with such provisions or this permit shall be deemed TRAILERu9E❑ GEor yINsPEenoN❑ No Spee Knowl ❑ revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY IN9PECTK)N LI Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter &APETY PERMIr❑ (USTnews eeLOw) *C] 9(commencing with Section 7000)of Division 3 of the Business No OF E9OTs and Professions Code and my license is in full force and effect-11 falne or Busine,80 License Number Lm Q Class S C SPACES Reov raovlDeo -SPACES I Contractor Date LIMITED TIME USE i - i ❑ I cin exempt from the licensing requirements as I am a momDATE To DATE licensed architect or a registered professional engineer acting m my professional capacity (Section 7051 Business 'azo oP and Profeuions Code) EzreTtNe aLne 4 t s�ron ei // SIGNATURE. Lic or Reg. No - Date PREeeNr Use OF BUILDING PT FINAL APPROVALD3 HOME OWNER-BUILDER DECLARATION No of ExIsnNG BUILDINGS ON LOT AND USE o!s I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 70315 Business and i Professions Code) NO PARKING O ❑ L as owner of the property will do the work and the arwcas PROVIDED structure is not intended or offered for sale(Section 7044,1 PROPoseD Use or BUILOINo e Business and Professions Code) i CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for (Sea performance )f the work for which this penult is issued PRoroscD wnx ccc Lender's Name APPLECANTr i TEL Lender s Address f2 99 I certify that I have read this application and state that the LCV -Gvn la �Tl above information is correct. I agree to comply with all County PERMrr Pee I ordinances and State laws rclatmg to building construction and hereby authorize representatives of this County to enter upon ISSUANCE fee the above-mentioned property for inspection purposes -- TOTAL Pee % Y7Ii{, SEE REVERSE FOR EXPLANATORY LANGUAGE I u of f4rmrtiee Date