HomeMy Public PortalAbout5604 ROSEMEAD BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION 7E6 876(11 114) M ISCELLANEOUS APPLICATION
7
I hereby affirm that I have a certificate of consent to setf COUNTY OF :,OS ANGELES BUTLOING AND SAFETY DIVISION
allure, Jr a certificate of Workers Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C) .�.
Poli o Company FOR APPLICANT TO FILL IN BU ORKSV�6
wow¢S
Ce ted copy IS hereby furnished eulLDINo O _ _ _ _ s �` LOCAL
XX wo ow[ee ka:r- �w�¢0.O4
Cert d copy is filed with the county bu Ing Inspection pLOCALIT 'Q- vCQ nn( pfO NEoew.:IT
depart ent ] [ r
Date Appl nl NEw Raer DISTRICT No am P TYPE CUSSED BY
cwoee ST �d CDNer
CERTIFIC TE OF EXEMPTION FROM ORKERS' LEGAL
C PENSATION INSURAN DUSCR[PTIGN Lor No [LOCK BA N w.wr
NG, Ic cul STATE row f6COND LOCAL
N
o or elDa•
(TIE section It not be completed d e work involved TRACT nor on Lor us[ zona •PEmwL CIPMDITIOPIS
by the permit Is r one hundred doll 1$100) or les,) uS90 P _
SIZE or Lor uheNG BLDG
1 certify that in the rformance of the ork for which o
permit Is issued, I Sha not employ any rson many BNEw of buildin
so as to become sub)ec to the Worker Compensation I-a s j o11 ��SA 1v OCCUPANCY GROUP
Mw IL W 1 G
ADOBES•
Date Appl nt _ t,, w
NOTICE TO APPLICANT If, after mg this Certificate of CITY CI ...ol P _OU
^ OCCUPANT LOAD V
Exemption, you should mine b)ect to the Workers APPLICATION FOR EXIT HARDWARE
Compensation provisions o he r Code,you must forth-
with Comply with such p vino s or this permit shall be rw AILEN INEGEOLOGY INSPECTION
deemed revoked ❑ ❑ Pa Spec /es
LICENSED CONTRA RS DECLARATION OCCUPANCY INSPECTION ❑ Pante DeV El
I hereby affirm that I am lice under provuhonsof Chapter SAFETY PERMM ❑ (LIST ITUMS BELOW)
9 (commencing with Section 7 ) of Division 3 of the Buer — NO orIre
ness and Professions Code,an in license a in full force a'kx
effect N4me of business Pw REINS w[ D PwovhDEo
SPwe[e
License Number Lhc Class S �L RQINC�S
LIMITED TIME USE
Contractor Date DAYK DA
Y.
I am exempt from t e licensing uvements as I am a PwDN
licensed architect a registered ofessional enghn^er SIZE GrRo Or IN PEcrom S
acting in my prof sional capacity ection 7051, Bus- EXISTING BLDG STORIES ONATIRE
messand Professho Code) PRESENT USE or Buv0. V1+ FINAL/APPROVALBUILDINGi
Ltc or Reg No Dat
HOME OWN R-BUILDER DECLAR TION No OF [x STING BUILDINGS 11V Al 7/25/95
I hereby 1 am exempt from th Contractor's ON LOT AND ISE 2 1554 1 PM12:57
J
License lawwfor
ort following reason (Section 031 5, Bnsr
ness and Professio Code) NO PARKING
1, as owner f theP to y,
ro rt will do the w and the SPACES PROVICKO
structure is not intended or offered for (Section
7044,Bust ss and Professions Code) �" /� p
CO STRUCTION LENDING AGENCY PROPOSED USE OF BUILDING Gy1 KFC
I hereby aff that there is a construction lending envy
for the perf rmance of the work for which this pe it IS
issued(Sec 97,Civ C)
Lender's No e
PROPOSED MAX Dec
Lenders dress
1 certify hat I have read this application and state that th PERMIT FEE
25,
above ormation is correct 1 agree to comply with all County ISSUANCE FEE
,ordma s and State laws relating to budding Construction,
and hereby authorize representatives of this County to enter rorwl TEE 2.5, ()�
on t above-mentioned propSEE REVERSE FOR EXPLANATORY LANGUAGE
erty for Inspection purposes
_.--1p --�{Q �J�,
Signal tire o Perm ttt& Date
1 UORLLRS CONIPLNSATIO\ DE(L\R\iI0\ 76MA44
^E 676 ,1641 MISCELL IINEOUS APPLICATION
1 hereby affirm art that I have a certificate Compen of Lonsent ,0 vett -
_r msure or a LerUhLateOt \NorAers Compensation Inwnnte or COUNTY OF LOSANGELES BUILDING AND SAFETY DIVISION '
a certified Lnpt thtteol (Set 38111) Lab ( I -
'_ I Policy No _Compass — -4pp LICA NT TO Fl LL IN
Certified tops is herebs 'urnulted auILOInG 56oq 1
E ADDRESS ., / KDSeme.•� j;(v , L,cALITv
1 I Certified Lnps is tiled %tilt the taunt, buildme mspLLU011 LOCALITY NCARear
department Temple City CIOSS ST
Dale \Dpinant NEARE9T Isrw lcT no 1w TO.. cEaaeD By
lcwOss sr Las Til s\QS P T' //
CERTITI( \TE OP E\ENIPTIO\ ER0\I 'l(`R6ERS LEGAL Y
170\IPf NS \TION INS( R\\(' ..SC.IPT On I LOT No SLOCX I— Ia,.R Al
Io IC,wC L[I NO STATE MAJOR SECOND LOCAL
wLOGS
(This section need not he tomolesed tf the \,nrA Imnhed -wAc- rlOsv]F ON LOT U9[ '�ONC 3rC C1AL CO NpIT1p Na
by the permit Is for ane hundred dollars ISI001 or less 1 t USE or
1 91$C Or LOT EXISTING MLOG
1 LertJs til u m tilt nt r,nrmm,r t ' t s + t O- ,h¢h his _
permit 11 'Ssu Ld I +hall tat mplo, in, ^,-wn Nan, mmntr $ oWNew 6"tIeS W O.
so as to hetomL Mdmett n the ttorker, I lnirLnQtto^ ' I%s ` pp OCCUPANC 3ROL'P L-
$1AO nest Ibo9 lh3 Cl� �)A((2 311 # .300
I Date \pnhcan[
NOTICE TO \PPLIC\\T It ve• -riAm_ , C,• _n,uc It $talc At6tAti drti CC19(903na (6 s(o)x$2-$Zg 2. 0CCUP4N-f OAC
E%eMDIln I ,Oil hnald hetom� +tuvec n ht 1`6"-
(ompens.ition
`6"(ompens.Iuon ern ision% aI ,ht I ibo 1& 1011 null milli I APOL'CA-I C'1' °`❑ =N'- -la=rl t=E
1 1,ith tomnN ,tith Guth ^rola on, o- III, Lrnn ,lull ht -PAILSR ISE '�_ 31.1- pec 111 N-Pec- 0N — No SK,cI if
l. f�
deemed Ltned I — 1--I
Ll( ENSLDl0\IR\(TORS DE(L AR ATION I occuPwncv INSPEc-ION 7� Panic Devres ❑
v I I herebs at'um hu I am hc.nsed undr ora tg0nc 0t C uaptL• SAr ET1 PcwMIT — (LIST ITEMS MELD v)
9 ILommemince -'til SeLtion •0001 of Dnlston 3 x the Rust- NO of EXIrs
ness and P-'IILWI1-11 Cod, and m, 'ice ite " to t 11 tore and
effeL r, wXING
9r _rs wco D •wo no¢o
LILLn,t NunlhL _ LL C'at1
-- Li14ITED TIME USE
ConlraLlnr _— flats 1.T• 0.-1
V
iT.
71
El 1 am e%empt Irom he ItLensmc reauvenents it 1 am I `
m 1 licensed arehutc• or T reztstered r•attatolnl entineer {size or No D• 'ruPEe pw a
z hlln_ n To pTOt '.fond iri_i, -. in +�
illi Rus SXnnnn eLDa S-.w'=; 9m UR[
ames,and I'•uRN1,n,L Id-1 — —
RE111T USE of BUIL]Ina FINAL APOROV AL r^`�
Lie or Ree \o , D, t__ - MJ
z l
RONIL (ANI R H( ILDLR Df:CL A'i \fIU\ INO or EXISTING BUILDINGS ,� /D
ON LOT AVO USE /(V•V I
1 herebs atrunt that I am L\cmpt Imm -fie Contnttor s I
( Lu-rise La% to, the fOl1U%m_ reason 'SBL non -",l _ Bu,I DI �
Ness and P•0tesvons Code no .wXa
I as +,%net of the property %ill do he %ort and the SPA CEsRlry
.R ovlo Eo _
strIlL are Is not Intended or otfered Int ..de IS,llion
704.1 Ru,ntLs,and PrnlLsanns(odLl g {'j�t11 j�
�P, 9,— 31'ii 7h %='•-
(ANSTRL('IION LENDING NGI V(1 PROPOSED USE Or BUILDING 0
I htrebs atfmn that there is a Lonstruction lendma Ietn,t
for tilt psrlormanec Of tilt norL tOr Muth this pLrnut Is
issued IS,t 3097 CIL C 1
LendLr,\a lie
PROPOSED MAX pec
Lenders \ddress
l 1 LLtntt that 1 hate trod flus appl%-Iriun trill ,tai Ihit tilt PERMIT FEE 25.00
above minrnution ts,orrett I IP-rLt tO LnmPI) %Ith all(ountV ISSUANCE FEE
ordimm.es and State lass relating to budding LonsttIlttion
s and hereby authorize representatnes of this Lounty to enter TOTAL. tee 25.00
t upon flit ibosc-menttontd polpert) for mspttbon purpose+
V,� 4 Z-7 t SI E RL N fRSC FOR EVE ANATORI LANGU\Gf•
C w„SI"En_alure of Permutee Date