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Home My Public Portal About5561-5563-5573 ROSEMEAD BLVD_Miscellaneous__ WORKERS COMPENSATION a cert DECLARATION CE 875 MISCELLANEOUS APPLICATION {1 CE 875 (11 841 LI 1 hereby y certificate ert the I have a certificate of consent to self COUNTY Off' LOS ANGELUS BUILDING AND SAFETY DIVISION insure, or n cert)cafe of Workers Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL INwn11 ess Certified copy is hereby furnishedLocw Llrr ILOING C 3 M D W AODR¢SS 7 Certified Copy is filed with the county building inspection cwurrrv¢ww eaT department -rf MG rCA 9 O cwoee Sr Date Applicant wo:.a werSr QQ VRQAPwA DISTRICT Mo 1 GROUP PrP P oca as¢D BY CERTIFICATE OF EXEMPTION FROM WORKERS' LeoAL O COMPENSATION INSURANCE O..CRvrl.. Lor Mo RLOCK ,GRRA o BLDOe noP jc,ncLw� STATE MAJOR SECOND LOCAL (This section need not be completed if the work involvedinvolvedry ed rwwcr No>dor oN Lor USE zoN¢ sreelwL CONDITIONS by the permit Is for one hundred dollars (f I00) or less.) usxe or /a I certify that in the performance of the work for which this SIZE OF LOT ¢ ISTINO BLDG o permit a issued, I shall not employ any person in any manner GwwER G c' ro a9 to become subject to the Workers' Compensation LawsMAIL , OCCUPANCY GROUP Date Apphcant AD DR ass107 67TLw NOTICE TO APPLICANT If, after making this Certificate of .1. OCCUPANT LOAD Exemption, you should become subject to the \Yorkers Compensation provisions of the Labor Code, you must forth- '70 APPLICATION FOR EXIT HARDWARE with comply with such provisions or this permit shall be deemed revoked rwwlL¢w USE GEOLOGY INsrecrloM No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS B¢LOvr) 9 (commencing with Section 7000) of Division 3 of the Busi- No OF EXITS ness and Professions Code,and my license is in full force and effect Pw RKIN6 OAC6• RE00 � FROVID 60 License Number Lic Class S O LIMITED TIME USE Contractor Dete GwTX ..To ❑ 1 am exempt from the licensing requirements as I am a T. licensed architect or a registered professional engineer SIZE or ND OP In SPECTOR s acting in my professional capacity (Section 7051, Bus- EXISTING ELDG STORIES rvwruw¢ mess and Professions Code) PR EYENr USE Or BUILD INO FINAL APPROVAL 3`Q Lie or Reg No Date Lf 7 HOME OWNER-BUILDER DECLARATION No or EX STING BUILDINGS 1r�1 0 1—r ON LOT AMD URE I hereby affum that I am exempt from the Contractor's Illlll"///...1• a License Law for the following reason (Section 7031 5, Busi- ness usrness and Professions Code) NO PARKING ElI, as owner of the property, will do the work and the ''ACES PROVIDED X11\ _214 structure is not intended or offered for sale (Section 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 1 hereby affirm that there is a construction lending agency RETAI+,., NERAL MERt.660 DISE for the performance of the work for which this permit is issued(Sec 3097,Cry C) Lender's Name PROPOSED MAX Bee Lender's Address PERMIT FEE I certify that I have read this application and state that the above mformattion is correct I agree to comply with all County ISSUANCE FEE ordmances and State laws relating to budding construction, and hereby authorize representatives of this County to enter TOTAL PEE upon the above-m uwn It p erty or inspecugn purposes / SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P n ee Date WORKERS COMPENSATION DECLARATION 76M444 CE 875 (2 80) MISCELLANEOUS APPLICATION I hereby afc mat I have certificate of convent to :elf COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure or a certrtlflcate of Workers' rs'Compensation Insurance or a cr(gifled copy thereof(Sec 3800 Lab C) Policy No Company FOR APPLICANT TO FILL IN ADDRESS Certified copy a hereby furnished BuiLDING � �r �� -q^ ADOR¢sa H 1! Loc nCertified copy u filed with the county building Inspection New e¢ar department OCALI T, eNo¢a aT Date Applicant NQAR¢aT T1rf_r-!"� .`a DISTRICT n GROUP Tr Pe PRo a Eo BY CROIIO fT 1 CLRTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE 0 ...,P"ON LOT NO BLOCK ".//I�D7� IGRW. No /VIS— �CIRCLRj arwr¢ MwiDR II¢co LOcwL 1 (Thu section need not be completed if the work involved NO of ELoca use zonE SPECIAL eonoiTlonII O TRACT NOW On LOT U by me permit a for one hundred dollars (5100) or less) ua¢ OR z¢ OR LOT Ex ISTINO BLDG I certify that in the performance of the work for which this O permit Is issued 1 shall not employ any person In any manner n!. R 17B31D MI . OF so as to become subject to the Workers Compensation Laws AIL �� l ,Y OCCUPANCY GROUP IL.J/CM/� W Date Applicant DDRKS-023]3w�'�'l �Q y1,y>C, Q NOTICP TO APPLICANT If after making this Certificate of eITYS&Q �. NOL 114— —S1O 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 USE OeOL OY INSPECTION deemed revoked ❑ C:] No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION CK Panic Devices 1 hereby affirm that i am la,ensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS oITL.WI NO OF EXITS 9 (commencing with Section 7000) of Division 3 of the Bus, ness and Professions Code, and my license Is In full force and SPACE D RED D PROVIDED effect PARKING License Number Lie Class LIMITED TIME USE Contractor Date DATE OAT. ❑ To I am exempt from the licensing requirements as I em a ,tensed architect or a registered professional engineer SIZE OFNo OF INSPECTOR S acting m my pro(essronel capacity (Section 7051 Bus- EA TING BLDG STORIES a NATURE mess and Professions Code) 10 4RESENT USE OF BUILDING SON FINAL APPROVAL Lie or Reg No Date HOME OWNER BUILDER DECLARATION On LOO NO ENT AND ND USE S.LOIN a I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason (Section 7031 5 Bos, ness and Professions Code) NO PARKING I as owner of the property will the work end the structure not intended or offered SPACES PROVIDED 346 1.8 A a intendedd for sale (Section n U # 0 W e 0 88 7044, Business and Professions Code) PROPOSED USE of BUILDING v / //Jr1 • S S S S S S CONSTRUCTION LENDING AGENCY TT c I hereby erfor that there Is a k for Ellin lending agency N V 0 J 0 9 7 8 6 for the performance of the work for which this permit is issued (Sec 3097 Civ C) Lenders Name PROPOSED MAX Dec Lender s Address PERMIT FEE I certify that 1 have read this application and state that the above Information Is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction TOTAL FEE and ere authorize re Dr enmtives of this County to enter u n t Wove mentione arty for Ins cl wI n purposes SSE REVERSE FOR EXPLANATORY LANGUAGE �o - Sig ure of Pernatt Date WORKERS CUMPC.NbAIIUN UCI.LAKA iLli'l 20-0003OPW12/ao Iv9. r_%j .3 liTlt—L.11\../"►i �vt1l I hereby affirm that I have a Certificate of Consent to self COUNTY OF LOS-ANGELES BUILDING AND SAFETY DIVISION vmsum or a certificate of Whkers' Compensation losnrancc, or a certified copy thereof (Set 3800 Lah C) Policy No. Company FOR APPLICANT TO FILL IN BUILDING I BUILDING ADDRESS ADDRESS 1 f ® Cerbfied copy is hereby furnished LOCALrTY - Certified copy is filed with the county budding Inspection cirY ZIP NEAREaT department C,tv q1790CRoss 5T t✓ Date '' Applicant SIZE OF L = NO OF SLDGS NOW ON LOT DlaratcT NO GROUP TYPE PROCESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS CONST O COMPENSATION INSURANCE TRACT ISLDCK LOT NO MAr K. STATE MAJOR SECOND LOCI,L (� (This Section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL No OC by the permit is for one hundred dollars ($100) or less) USE ZONE SPECIALCONDITIONS No 4 lel TEL I certify that in the performance of the work for which this TEL _I permit is issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws. ADDRESS a I o2 OCCUPANCY GROUP Z Date Applicant Ctry ZIP NOTICE TO APPLICANT If after making this Certificate 922367 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 UBE❑ GEOLOGY INSPECTION El revoked No Spec Know) E-1 OCCUPANCYr}� El INSPECTION L.a PSRIC DBVICBS LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter SAFE7N PERMIT❑ (LIST ITEMS BELOW) ' 9(commencing with Section 7000)of Division 3 of the Business �e o tis Sae NO OF EXITS and Professions Code dnd my license Is In full force and effect PARKING REQ o � rROVIpED License NumberGe C Class SPA .J I Contractor Date LIMITED TIME USE ElI am exempt from the licensing requirements as I am a Owre DATE FROM To Licensed architect or a registered professional engineer ns acting in my professional capacity (Section 7051 Business SIZE F a No Or CC R•S and Professions Code) E[ISTIONG w BLDG 9,2�Q STORIES B A R[.. Lic or Reg. No - Date PRESENT USE OF BUILDING FINAL APPROVAL —7—03 HOME OWNER-BUILDER DECLARATIONNO OF EXISTING BUILDINGS 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, as owner of the property will do the work and the ACES PROVIDED structure is not intended or offered for sale(Section 7044 1 rROPOs[D USE OF BUILDING Business and Professions Code) 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 (See 3097 Civ C) PROPOSED MAX Oce Lender's Name AFPLIGMrRVIq LI 162E .�7/-663 Lender's Address ADDRESS 'above that I have read flus application and state that the e, ,e 1776 above information s correct I agree to comply with all County ordinances and State taws relating to building construction and PERMR PEE hereby authorize representatives of this County to enter upon ISSUANCE PEE 't, , the above-mentioned property for inspection purposes - g��f,�,/'� t TOTAL FEE " L� �'Z—�/Z70()'�SEE REVERSE FOR EXPLANATORY LANGUAGE Asignature of Permittee Dike