The URL can be used to link to this page

Home My Public Portal About5551, 5553, 5557 ROSEMEAD BLVD_Miscellaneous__ WORkERS'COMPENSATIONDECLARATION CE 875 111 a41 MISCELLANEOUS APPLICATION {� CE 876 LJ 1 hereby Safeco that I have a certificate of consent to self 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 No Company FOR APPLICANT TO FILL IN DUwDOwILO,aNO .a Q Certified copy Is hereby furnished woBUDRILDsae 6 U.L.D.N. 155-7 ,EMQ'f4 R 14 LID ewurr � ❑ Certified copy is filed with the county budding inspection LOCALITY NEAREST T Date Applicant NEAREST OII yeICT NO Rou• TYPE r cQ Q r CROSS ST /. Q CON°T CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE OR.C..Pnon Lor No BwcNMAP or XO u c LXY .TATs Mwaow °aeon° LOCAL eLDOE (Thu section need not be completed J the work involved rwweT nNOow on Lor USE =N9 SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less) USE or SIZE Or LOT E%..TING SLOG 1 certify that m the performance of the work for which this 1n o permit u issued, I shall not employ any person many manner OWNER (V z`) ` , LD so as to become abject to the Workers' Compensation Laws MAI a%� OCCUPANCY GROUP o Date Apphcant ADDw QEE w U NOTICE TO APPLICANT If, after making this Certificate of cITT5VKU A76NoL 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 TRAILER USEGEOLOGY INSPECTION deemed revoked ❑ E] No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONW Panic Devices 1 hereby affunt that I am hcensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busy °^"aTv PERMIT E] (tier ITEMS EQLow) NO or EXITS ness and Professions Code, and my Incense u in full force and effect l IZ'Z- PARKING RCDD PROVIDED License Number Lic Class LIMITED TIME USE Contractor Date Al.DDAY. I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE orno or .NSPECTow ¢ acting in my professional capacity (Section 7051, Bus- EXISTING BLD. .Towle. s NATUE mess and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING Lic or Reg No Date HOME OWNER-BUILDER DECLARATION No or EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Bust- ODW-M 5/15/90 ness and Professions Code) NO PARKING I, as owner of the property, will do the work and the SPACE. PROVIDED I]6$] 1 X11%01 structure is not intended or offered for sale (Section 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING p(�� I hereby affum that there is a construction lending agency , for the performance of the work for which this permit is 8� � i issued(Sec 3097,Cry C) li_k�t Lender's Name 1 l U PROPOSED MAX DCC /1\ Lender's Address PERMIT FEE I certify that I have read this application and state that the above ud'orrnation is correct I agree to comply with all County ISSUANCE PEE ordinances and State laws relating to budding construction, and hereby authorize representatives of this County to enter TOTAL FEE 25-P-1111- upon the above-mentioned property for inspection purposes 1/ SEE REVERSE FOR EXPLANATORY LANGUAGE / Y Signature of Permittee Date WORKERS COMPENSATION DECLARATION CE 875 (2 80) LJ MISCELLANEOUS APPLICATION ,�1 CE 876 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insure or a certificate of Workers'Compensation Insurance or a certified copy thereof(Sec 3800 Policy No Company Hu1Lo1Na t 7 R '' /J FOR APPLICANT TO FILL IN ADDRESS J S�j ❑ Certified copy Is hereby turns ea lC p�Jy��{r DUILolNa LOCALITY ADD jei Certified copy is filed with tou b i mg inspection TE.�'ooi / C / de a men LOCALITY TE fi NROREST caosS sr Dale Appllcan •� Newaesr /� ��7 d oierRlCT No GRID uP TYPE Roc tl: HY cRoss ST (Ca IN Y D� r CON CERTIFICATE OF EXEM ION FROM 44ORKERS LEGAL 'ncJ COMPENSATION INSURANCE Deet RlFTion Lor No eLoc% MAo / „la„NA OO N (c Iw CL¢I STATE MAJOR SECOND LOCAL } (This aectlOn need not be completed if the work involvedTRACT Xow oN Lora USE ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars (SI00) Or less) USC TI 7�� G G� — V SIZE OF LOT E%[aTiNa GLO G![ I certify that m the ll not mance of the work for any which this I •�T `sw��- S permit Is issued 1 shall not employ any person in any manner owNHR l .J O so as to become subject to the Workers Compensation Lasts MAIL OCCUPANCY GROUP ADDaesSF $(/flyS w Date Applicant d N NOTICE TO APPLICANT If after making this Certificate of ctry NOTML OCCUPANT LOAD Z 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 USEGEOLOGY INSPECTION deemed revoked ❑ ❑ No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO OF Hxlra 9 (commencing with Section 7000) of Division 3 of the Bust ness and Professions Code and my license is In full force and effect rwR%Inc SPACES REGD PROVIDED R License Number Lm Class LIMITED TIME USE Contmetor Date DATA DAT. ❑ IR M ro I Sm exempt from the licensing requirements as I am a i I architect or a registered professional engineer SME Or S- ')o ND Or INSPECTOR s acting in my professional capacity (Section 7051 Bus- ExiSTIFG BLDG J STORIES SIGNATURE mess and Professions Code) �•f-#/L FI NAL APPROVAL PRQSH NT USE OF BUILDING O P'y Lm or Reg No Date— HOMEOWNER ateHOMEOWNER BUILDER xemDECLARATION rheCo No OF H%tSTING USE ami.mNas K— I ON LOT AND USE Tp' I hereby affirm that I am g exempt t from the Contractors '� � 1 7 7 3 A License Law for the following reason (Section 7031 5 Bust C ness and Professions Code) NO FARING I I ' ❑ I, as owner of the property will do the work and the structure Is not intended or offered for sale (Scction �s A,•�• • • • • 2 7044 Business and Professions Code) PROPOSED USE OF BUILDING �. T /L I 030-81 3O-81 CONSTRUCTION LLNDING AGENCY I 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 Lender's Address PERMIT FEE I certify that I have read this application and stale that the ISSUANCE FEE aboce Information Is correct I agree to comply with all County ordinend State laws relating to budding construction TOTAL P �d on arab Soil Fe represen[atrves of this County to enter S. n ab ant pntativv for his Coo SEC REVERSE FOR EXPLANATORY LANGUAGE \ nal re of Permittee400000, Ste WORKERS'COMPENSATION DECLARATION 79[w4aa_ CE 976(11 84) MISCELLANEOUS APPLICATION {� L1 I hereby -aRtrm that 1 have a certificate of Covent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ins'n, or a certificate of Workers'Compensation Insurance,or a Certifiedy thereof(Sec 3800, Policy No pECompany ITFOR APPLICANT TO FILL IN emiaiwG woDRe• FiCertified copy a hereby furnished UILDING 16- Loew Lrrr 1 ADDRESS ..+ CCert rtm copy a tiled with the County building mspectso OCAurY ' •CI C CELS!ST Date 72k Appliant�amnAC� rnq NEAREST Drerwi r no a u• rxr[ <[[S[D By CROSS Sr r D ! _� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O COMPENSATION INSURANCE DESCRIPTION Lor No BLO CX wo• j�IS C�a STATE Mwrow •EeonD LOCAL No or BLDae (Tho section need not be completed if the work involved TRACT now on Lor USE son[ Sr[¢IwL conolrroN• by the permit is for one hundred dollars ($I00) or less) ESS[ or I certify that m the performance of the work for which this SIZE or Lor EXISTING BLDG permit a issued, I shall not employ any person many mann wNER of buildin Q S o U so as to become subject to the Workers' Compensation Law— MAIL OCCUPANCY GROUP o woowa[S Date Applicant V' I w NOTICE TO APPLICANT If, after making this Certificate of err a P4 woL 29WOCCUPANT LOAD Exemption, you should become subject to the Workeri Compensation provisions of the Labor Code,you must forth, APPLICATION FOR EXIT HARDWARE with Comply with such provisions or this permit shall be TRAILS* ms ❑ aroLoav mn[cnoN ElNo Spec Knowl deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bun- NO PERMIT (LIST NEM.BELOW) No oP [xrrt ness and Professions Code,and my license a m full fora effect alae f business PARKING REO o Pwov,DED License Number ss SPACES Lic Clan ' I LIMITED TIME USE Contractor Date DATA _ TAYS ❑ I am exempt from the licensing requirements as I am a IRDM TO _ - licensed architect or a registered professional engineer SIZE or No or INSPECTOR rC acting in my professional capacity (Section 7051, Bus- EXISTING BLDG Sro.I[S - - r., _ mess and Professions Code) FINAL APPROVAL r PRESENT u[E or BUDING J, i Lic or Reg No Date HOME OWNER-BUILDER DECLARATION NO or EXISTING BUILDINGS •' ON LOT AND USE I hereby afar that I am exempt from the 0315,Contractor's License Law for the following reason (Section 7031 5, Buo- ness and Professions Code) No PARKING 1, as owner of the property, will do the work and the SPA CUE PROVIDED structure a not intended or offered for sale (Section 7044,Business and Profemom Code) CONSTRUCTION LENDING AGENCY PROPOSED ESS[or BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit a awed(Sec 3097,Cry C) Lender's Name PRoroe[D MAX OCC Lender's Address I certify that I have read this application and state that ther ai_T?!, above information is correct I agree to comply with all County Ts [ ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter 116orwL [ 25,010 upon the b ve-mentioned property for inspection purposes. n - SEE REVERSE FOR EXPLANATORY LANGUAGE Date r , I WORKERS'COMPENSATfONDECLARATK)N 73O ,,,,12/110 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION mm e,or a certificate of Workers Compensation Insurance, or ( � a certified copy thereof(Set 3900 Lith. C) - ' FOR APP Policy Na Company APPLICANT TO FILL W Iais.Oi»D DIXiE98 ADOREBa ® Cerufned copy Is hereby furrushed O LOCAsri'r Certified copy is filed mth the county building inspection a zIP ' department r� �xi� Date Applicant SIZE P L NO Or BLDGS NOW ON Lor DIQTTiICT NO GAWP nFE PROCESSCD m e CERTIFICATE OF EXEMPTION FROM WORKERS coNST C ( , TRACT tsiDCX IDT NO COMPENSATION INSURANCE R.. MmIVA. ` STATE MAJOR SECOND LOCAL (This sectlun need not be completed if the wort( Involved ASSESSOR MAP BOOK PAGE PARCEL G by the permit is for one hundred dollars ($100) or less) ilsE zoNe SPECIAL CONDrTIONf }t i 1 certify that in the performance of the work for which thisannee L C I permit Is issued. I shall not employ any person In any mr 13 ro as to become subject to the Workers Compensation Laws. ADDRESS n Lai 1�11 l,, C OCCUPANCY GROUP v t Tate Applicant CIT --F IP NOTICE TO APPLICANT If after making this Certificate OCCUPANT LOAD of Exemption you should become subject to the Workers APPLICATION FOR Compensation provisions of the Labor Coda you must forthwith EXIT HARDWARE ( comply vnth such provisions or this permit shall be deemed "Alirn USE❑ eeol ylNamcnoN❑ No Spec Knovd ❑ revoked r� LICENSED CONTRACTORS DECLARATION occuPANCY INSPECTION(I Panic Devices ❑ I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMR❑ iiJsr rteMa eELowl No of"" r , 9(commencing with Section 7000)of Division 3 of the Busmess t o UH ese and Professions Code and my license Is in full force and effect PARKING REO D E= PROVIDED License Number Lic Class SPAces t I Contractor Date LIMITED TIME USE ❑ I am exempt from the licensing requirements as I am aDATro E OArE licensed architect or a registered professional engineer acting in my professional capacity (Section 7051 Business au of NO OF n+ , roR s ( I and Professions Code) EXIBriNG aloe aTORICa SJGNATURe, LIB or Reg Na Date PRESENT Uae OF aulLDwe FINAL APPROVAL `� 1 Z 6 Q_ i HOME OWNER-BUILDER DECLARATION NO w ExiartNG Bull-DINGS 6— ON Lor AND USE I hereby affirm that I sm exempt from the Contractor s License Law for the following reason (Section 70315 Business and ( Professions Code) NO PARKMG ❑ I as owner of the property will do the work and the SPACES IROVIDED structure is not intended or offered for sale(Section 7041 1 PROPOSED USE of BUILOINa I Business and Professions Code) 1 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 PROPoseo MAX Oce ( , (Sec 3097 Civ C) Leader's Name 31 APPLICANTImrR) TE NO a- Lerida s Address ADOREBS ( I I certify that I have read this application and state that the above Information is correct. I agree to comply with all County mRMir FEE ordinances and State laws relatmg to budding construction and hereby authona representatives or this County to enter upon reaII Mff f I I the above-mentioned property for inspection purposes. I TOTAL FEE Ili D SEE REVERSE FOR EXPLANATORY LANGUAGE Sitnature o ee Dam WORKERS (,UMrLNWiUN Lit! .LHMnILVir 16DO63lWw„2r100 til l+.7vL4.,Ll1�11..v vv A .. I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION u vtncerrotifor copy thereof certfficater W rkws Compensation Insuraoccl or a Policy No Company FOR APPUCANT TO FILL IN BUILDING BUILDING ADDRESS wODReas ® Certified copy is hereby furnished X spsss 9050maAa SLY&, LouLITv Certified copy is filed with the county budding Inspection crry zIP NEAREST department 'r 9 r CRO"ST Date P Applicant SIZE OF LOT NO OF BLOGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS `�'TRr IrrA coNar O COMPENSATION INSURANCE TRACT BLOCK LOT No MAr IIwNwAr V IO STAT!MAJOR SECOND LOCAL (This section need not be completed If the work Involved ASSESSOR MAP BOOK PAGEPARCEL by the permit is for one hundred dollars ($100) or less) 10.5, $ �88r USEZONE SPECIAL coNDmw+e L certify that in the performance of the work for which this vNapgrry wrier TEL NO permit is issued. I shall not employ any person in any manner9r 497 Ifo 1 so ss to become subject to the Workers Compensation Laws ADOREssC O No$L6 111NW78artcam do �� OCCUPANCY GROUP z Date Applicant Cm ZIP NOTICE TO APPLICANT If after making this Certificate OR �?;LV467 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❑ GEOLOGY INSPECTION❑ NO Spec KnoWl ❑ revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION(I Panic Devices ❑ 1 hereby affirm that I am licensed under provisions of Chapter SAFCTY PERMIT❑ (LIST REMS BELOW) 9(commencing with Section 7000)of Division 3 of the Business NO OF EXITS and Professions Code .rid my license Is in full force and effect ame ot Busixtess PARKING RED O PROVIDED i License Number Lic Class o Fabaie, dba q (1 SPACES JJ I Contractor Date LIMITED TIME USE i ❑ I am exempt from the licensing requirements as I am aDATE DATE licensed architect or a registered professional engineer FROM TO acting in my professional capacity (Section 7051 Business SIZE OF q NO OF INSPECTOR'S and Professions Code) EXISTINGBLDG O�D STORIES I SIGNATURE. Lia or Reg. No - Date PRESENT USE OF BUILDING C�QFINAL APPROVAL 11191K I F HOME OWNER-BUILDER DECLARATION No of exlsnNe auaol s 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 Professions Code) NO PARKING I ❑ I, as Owner of the property will do the work and the ACES PROVIDED structure is not intended Or offered for sale(Section 7044 1 PROPOSED USE OF BUILDING R Business and Professions Code) pfiibil r, 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 (Sea 3097 Civ C) PROPOSED MAX Oce Lender s NameAPPLIUNT IHWTJ TEL NO Q Lender's Address ADDRESS A in � i I certify that I have read this application and state that the 'Z g67 above information is correct I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction and hereby authorize representatives of this County to enter upon ISSUANCE FEE , t the above-mentioned property for inspection purposes - TOTAL FE! 2-I 03t SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pennit ee Date