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Home My Public Portal About5546 ROSEMEAD BLVD_Miscellaneous__ WORKERS COMPENSATION cert DECLARATION CE 875 M ISCELLANEOUS APPLICATION CE 876(11 841 Insure, o affirm that 1 have a certificate of torment to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers Compensation Inwmnce,or , a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN .ulLD Ina lr�� y� wooweu Certified copy is hereby furnished CE G _ pooR e 5546 ROSEMEADLa.A—,F-1Certified Copy m filed with the county budding inspection Gc.urr NtwweeT department TEMPLE CITY CA. 91780 CROSS ST Date Applicant RE/T DIS rip aR uP rr ESstD Br cwoRS ST r BROADWAY CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE o...RIFT... LOT NO CLOCKA• I...w n0t<.wCL/I STATE MAJOR SECOND LOCAL NO OP =LOGS (Thin section need not be completed if the work mvohed rwwcT nor on ws mea zont SPt mwL cowmnowe by the permit is for one hundred dollars ($100) or less) met or Snit Or LOT Elf i/TING BLDG 1 certify that in the performance of the work for which this o permit Is iswed, I shall not employ any person in any m owmak Of LOT `-' so as to become subject to the Workers Compensation Law Mw 01 L OCCUPANCY GROUP Date Applicant ADDRESS 15801 VALLEY BLVD. TEL NOTICE TO APPLICANT If, after making this Certificate of C.TY LA PUENTE No (818) 333-51rl OCCUPANT LOAD o_ Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER met ❑ GEOLOGY INSPECTION ❑ NO Spec KnoWl deemed reioked El LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEM/ BELOW) 9 (Commencing with Section 7000) of Division 3 of the Busy ❑ NO OF EXIT/ ness and Professions Code,and my license is in full force a effect T business PARKING SP SCIS REGD = PRoviDto License Number Lic Class PRESTIGE FORD SALES INC. LIMITED TIME USE Contractor Date GRT. PAT. T. El 1 am exempt from the licensing requirements as I am a "- licensed architect or a registered professional engineer SIZE orNo or INSPECTOR e acting in my professional capacity (Section 7051, Bus- EXISTING BLDG Sro.IES SIGNATURE mess and Professions Code) - _ PRESENT u/E or BUILDING FINAL APPROVAL Lic of Reg No Date HOME OWNER-BUILDER DECLARATIONNN LOT AND G or SX unwUStG BUILDING/ ON I hereby affirm that I am exempt from the Contractor's V a� License law for the following reason (Section 10315, Busr Ness and Professions Code) No PARKING t, as owner of the property, will do the work and the SPACES PROVIDED structure m not intended or offered for sale (Section 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USt Or BUILDING 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is ensued(Sec 3097,Cw C) Lender s Name PROPOSED MAX Occ Lender's Address 1 certify that 1 have read this application and state that the PERMIT FEE 25. 00 above information is correct 1 agree to Comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives this County to enter TOTAL FEE 25. 00 upon thea e-mentioned pro r inspection purposes �I 7-14-95 SEE REVERSE FOR EXPLANATORY LANGUAGE SIFn9trlre of Permittee Date WORKERS'COMPENSATIONDECLARATfON 3DPW12,9O MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �tnsum or a certificate of Workers'Compensation Insurance,or ( a eertLfted copy thereof (Set 3800, lab.C) Pbhoy Na Company FOR APPLICANT TO FILL IN BIRLDING ADOR 6 ADDwIns 8 Certified copy is hereby furnished BUILDING 12�7 1 Certified copy Is filed with the county budding inspection :- /T ZIP y 7S� Nlswwm department. 16cRoss[T Date ' ApplicantSIZE OF LOT NO OF 81 DIG NOW ON LOT daTR,CT NO GROUP TY►6 PROCEaSED eY I CL CERTIFICATE OF EXEMPTION FROM WORKERSconst 0 ( COMPENSATION INSURANCE TRACT BLOCK LOT NO V w 10.R , [TATE MAJOR SECOND LOCAL (This section need not be completed If the work Involved ASSESSOR MAP BOOK PAGE PARCEL by the permit Is for one hundred dollars ($100) or less) USE zoN[ SPECIAL coNorrawa 0 f I certify that in the performance of the work (or which this @ Ta ND L permit is Issued I shall not employ any person In any manner l C/ — 0% so as to become subject to the Workers Compensation Laws ADDRESS a O ` 14 OCCUPANCY GROUP _Z ( , Date Applicant CITY ZIP NOTICE TO APPLICANT If after making this Certificate 1 I M'6 OCCUPANT LOAD of Exemption you should become subject to the Workers APPLICATION FOR Compensation provisions of the Labor Code.you must forthwith EXIT HARDWARE comply with such provisions or this permit shall be deemed TRAILER USE[I GEOLOGY INSPECTION El No Spec Knowl ❑ revoked LICENSED CONTRACTORS DECLARATION OccuMNCY,NaI•eCTION[a Pani:Devices ❑ 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) f , 9(commencing with Section 7000)of Division 3 of the Business �e o U8 e8s NO OF[XITa Ll and Professions Code and my license is In full tome and effect MACES weD D Pwov,Deo O � License Number L¢ Class � GJ�/ � ��i� D' SPACES ( Contractor Date UMITED TIME USE Dwre DATE Elm m IwoM I aexempt from the licensing requirements as I aa To licensed architect or a registered professional engineer ( acting In my professional capacity(Section 7051 Business 53 HOP No or INSPECTOR S and Professions Code) EXISTING a DG SITORI[a a,GNATJRE. Lie or Reg. Na_ Date PR®ENT us[OF BUILDING FINAL APPROVAL i HOME OWNER-BUILDER DECLARATION No o1 EXIanNG eulLniNcs ON LOT AND USE I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 70315 Business and 1 Professions Code) NO PARKING i ❑ I as owner of the property will do the work and the SPACE[PROVIDED structure is not Intended or offered for sale(Section 7044 1 PROPOSED USE OF BUILDING Business and Professions Code) 1 5 i LJ-t�n 7s CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is Issued ( I P (Sec 3097 Civ C) r+oPoeeD MAX OCC. Lender s Name w J i m No Lender s Address A00 ( I certify that 1 have read this application and state that the H �� '�Z( % I'JSZ7 above information IS correct. I agree to comply with all County I,R, S. ordinances aDd State laws relating to budding construction and hereby authorize representatives of this County to enter upon Ia9UANCH fee I it the abov entio d roperty for inspection purposes TOTAL I[[ % i R 6Z SEE REVERSE FOR EXPLANATORY LANGUAGE Slane{ re of Permittee Date