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Home My Public Portal About5546 #103 ROSEMEAD BLVD_Miscellaneous__ WORALRS CUMPLNSAfION Ix( I ARATION "'INMISCELLANEOUS APPLICATION i,uO]1, I1PW 11 ou I hereby aITirm Ilial I h nL a LCI II IL UL 01 Ln0,L11I (41 ,Lu COUN 1 Y OF LOS ANGFLES BUILDING AND SAFELY DI VIS Im' II Insure,or a Lcrul Ican of Workers C OmpLIl,111011 111,111 inLL or a certified cop) thereof (Sec 1800 Lab C 1 POIILy No (nnlp,ury FOR APPLICANT TO FILL IN BUILDING BUILDINC&iIkpDRE7ADORLSS H (citified LOPy is herLb) tunusliLd LOCALITY Certified copy Is Ided with thecount) budding ut,PLLuon cIT ZIP1 rte` p �J , T NEAREST department V CJ� cROBS 6T Date Applicaill SIZE-OF LOTt NO OF BLDG NOW ON LOT DISTRICT NO GRDUP TYPO PROCESSED BY CONST 1 ( LR-111 R AI I OF LXEMPIIUN I ROM WORILI ICS TRACT BLOCK LOT NO ,J COMPENSAI ION INSURANCE •^ mow•• M Icwa.El STATE MAJOR SECOND LOCAL (This seLlloll need not be Lomplcled If the wlRk in,(1,Ld ASSESSOR MAP BOOK PAGE PARCEL ) by the permit Is for out. huadrLd dullms Is 100) in iI.%% USE ZONE aPECIAL CONDITIONS f `f I Leruf) that In Ihl perform UILL OI IhL xnrk 1111 x110.11 IIII, OWNER-, TEL NO pLrmu Is hued I shall 1101 employ m) Inlslm m m) in ulcer / 11 so as to become subject to the Workers Coinlxmation axs AD Res GR5 a OCCUPANCY GROUP r' Date _ APPIIL int c zIP /� O NOTICE TO APPLICANT II altLl making this (Lnlll, Ile OCCUPANT LOAD of Exemption jou should become subjeLI 10 the WO I.Ln APPLICATION FOR Compensation pro,Isions of the Labor Code )ou must forthwith I-I EXIT HARDWARE comply with such pro,Blons Ili this It-nnit ,hill bL 11WIlLd TRAILER USE LI�J GEOLOGY INSPECTION LI _I No Spec Krhowl revoked ❑ LICENSED CONTRA(fORS DL(I AR %1-10NoccuPANcr wsPEcrloN)� Penin Devices El 1 hereby affirm that ' In- licensed under provisions 0I ( h ynLr SAFETY PERMIT❑ ILIST F EMS BELOW I J i 9(commencing with r LI Dn 70001 of D1,ishan )of th, Business No or EXITS and Protesstuns CodL aid my IICUIse N UI lull Ione uid LffLu C PARK NG cF L^IN�S7 a I License Number I u ( I n, x SPACes REQ o E= I PROVIDED r _ 1 (onuaLwr UuL "—,.CL, — -- LIMITED TIME USE DATE DATE El I am exempt from the licensing ayinnmems as I am a FRDM To hLensed architect or a reglslLred prolissi,inil Ln)mctr acting In Ill) prolcsslunal LapaLlt) (SLLuon 71151 RUanL,s SIZE OF NU OF / WSPECTOR5 `-1 and PrulLssiorls(odL) Exre TINL.BLDG STORIES SIGNATURE LIc or Reg No uJll PRESENT USE Of BUILDING FINAL APPROVAL HOME OWN[ R-111111 DI R DI ( I ARAIION NU Or L%ISrING ILD1NGs I uN LOT AND USE I I herebyall inn th ht I ant LSLIn PI Iron 1hL(OntrlLI0I , l LLIISL Law for lhL following reason 1SLLNun 70113 BusnlLss and I Profmicas (ode) NO PARI(ING SPACES PROVIDED I I as ,r,nLr til Ilse Pnlpu 1, xdl do IhL xlnk Hill III, — struLturL Is not intendLd lir Ul1ULll IDI NAIL llLllkm 7114.1 PROPOSED USEOF BUILDI I Business and Professions Code) . 1 I 0 1 CONSTRU(TION 1 LNDIN(I AGI N( ) I heTLhy 1111M III It IST is d consuuLlllm ILndulg IEUL) fit, the pLtUrmanLL of the Wolk for whlLh IhIN IhrnUl Is nsuLd (.See 3097 Civ ( ) PROPOSED MAX OCC Lenders Name --_ _ APPLICANfflbRl - 6. LN x p ( Lender s Address O 101 1 certify that 1 have read this apphLatlnn and sLuL Ili II IhL ADOR �' !� �� above Information iscorrect I agree to comply with all(uunly PERMIT FEE ordinances and Slate laws relating to budding construt.w o lint hereby authorize reprewmallNes of this Count) to entLl upon 1581 FEE f the above-mentioned property for InspLLtltm purp,,x% `^' r TOTAL FEE V IIs I Of SEF REVERSE FOR EXPLANATORY LANGUAGE Sipyfirclor Permnne 1141E WORKERS COMPENSA710N DECLARATION 1;4 0OOJ t2/]0 2MISCELLANEOUS APPLICATION 1 20 n I hereby affirm that I have a certificate of consent to sap COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION msure,or a certdreatL Of Workers Compensation Insurance o B certified copy thereof (Sec 3NO Lab C 1 Policy No Company _ _ _ _ _ ' FOR APPI-CAN I TO FILL IN Sun DING eBUILDING ADDRESS ADDRESS Certified copy Is hereby furnished #Ia,3 ICJ ALITY Certified copy is I ded with the county budding Inspection CIT ZIP (� li department M 1 ® NEAREST ` CROSE ST Dalt Applicant _ _ SIZE OF LOT NO OF BLDGS NOW ON LOT DISTR T NO GR TYPE CEssED BY CERTIFICATE OF EXEMPTION FROM WORKERS ,Q� toper 1 COMPENSATION INSURANCE TRACT SLOCK LOT NO ¢)RCL[ STATE MAJOR SECOND LOCAL (This SCcllon need not be Completed if the work moolsed ASSESSOR MAP BOOK PAGE PARCEL USEZONE SPECIAL CONDITIONS by the pe Tm( is fur one hundred dollars 15100) or less) 1 certify that In the performance of the work for whlLh this Ifo Ta permit a Issued I shall not employ any person m any manna A DRE so as to become subject to the Workers Compensation Lave OCCUPANCY GROUP Date Apphcanl i ZIP NOTICE TO APPLICANT h after making this Certillcaiepl'I I 8 OCCUPANT LOAD of Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code you must torthwah comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ revoked No Spec Krwwl ❑ LICENSED CONTRACTORS DECLARATION I OCCUPANCY INSPECTION[I Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) a 9(commencing with Section 7000)of Diodonhe Business NO OF EXITS 3 of t and Professions CodL and my license is in full force and effect =-7— REO D D PROVIDCD O License Number _ Lm Class ______ _ _ SPACES r Contractor Date LIMITED TIME USE ❑ 1 am exempt from the licensing requirements s as 1 am J FROM To DATE licensed architect or a registered professional enginecr acting in my professional capacity (Section 7051 Business SIZE OF NO OF INSPECTOR S and Professions Code) EXISTING BLDG STORIES SIGNATURE Lie or Reg No _ _ Da0. _ __ PRESENT USE OF BUILDING FINAL APPROVAL HOME OWNER-BUILDER DECLARATION NO OFEXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contr ictor s LiLenstX Lew for the following reason (SLctiim 70715 BusmLss and O\/y\ Professions Code) NO PARKING I as owner of the proper[} will do the wort and the SPACES PROVIDED structure is not Intended or offered for sale(Section 704,4 PROPOSED USE OF BUILDING Business and Professions Code) RQ-tok,k �t stvarz lid CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for COIQ L I s the performance of the work for which this permit is issued (Sec 3097 Co, C) PROPOSED MAX OCC Lender s Name APPLICA —TI E No Lender s Address ADDRESS 1 certify that 1 have read this application and state that the above information is correct I agree to comply with all County PERMIT FEE ordinances and State laws relating to budding construction and hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned roperty for Inspection purpo 7 s /' � TOTAL FEE '� C— O!] SEE REVERSE FOR EXPLANATORY LANGUAGE Slg lure of 14 ntee to