HomeMy Public PortalAbout5620 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION MISCELLANEOUS APPLICATION
CE 875(17-84)
I hereby CE 875 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,Lab.C.).
Policy No. Company i FOR APPLICANT TO FILL IN
Certified copy is hereby furnished. �[ BUILDING L.L� U� LOCALITY
L` ADDRESS V�
Certified copy is filed with the county building inspection LOCALITY ` p� NEAREST
!
department. 017 `' CROSS ST.
Date � Applicant NEAREST DISTRICT NO. I GROUP OS ST. CONST. PROCESSED BY
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
_ NO. OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. >'
n_
permit is issued, I shall not employ any person in any manner X OWNER y
so2i]as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
ADDRESS I--'
Date Applicant w
TEL. OCCUPANT LOAD o_
NOTICE TO APPLICANT: If, after making this Certificate of CITY No. 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 oI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 0
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW
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. SPACESG REQ'D = PRO-ID 6D
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S
acting ]ri my professional capacity (Section 7051, B115- EXISTING BLDG. STORIES yj;r _IS:IGNATURE
iness and Professions Code). I
y I�
PRESENT USE OF BUILDING F� AI.APPROVAL
Lic.or Reg.No. Date /� L—
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGSA r'e1 .-
ON LOT AND USE i_r' '1e
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
0 I, as owner of the property, will do the work and the ''PACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
X PROPOSED USE OF BUILDI G -� A
CONSTRUCTION LENDING AGENCY '
I hereby affirm that there is a construction lending agency °L,PJ
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). Py
Lender's Name
PROPOSED MAX. OCC. '
Lender's Address
PERMIT FEE 9!51
I certify that I have read this application and state that the
above information is cor ect.I agree to complyIvitlt all County ISSUANCE FEE
ordinances and State 1 vs relating to building construction,
and hereby authorize re resentatives of this County to enter TOTAL.FEE ,
upon the above-mentione p for inspection purposes.
SEE REVERSE FOR EXPLANATO$Y LANGUAGE
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION CE 874(1 1-84) MISCELLANEOUS A P P L I C AT I O N
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or
a pertified copy thereof(Sec.3800,Lab.C.).
A 7u�d
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS 2V XiU4
M Certified copy is hereby furnished. Ci :7_UILDING 1[7CALITY
ADDRESS Rosemead Blvd. Temple
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant REST d as DISTRICT N p TYPE PROCES D BY
ROSS ST. •CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIG Nw Ar STATE MAJOR SECON LOCAL
NO. (CIRCLE)
NO. OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPE CtAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this o
permit is issued,I shall not employ any person in any manner N wNER Rensac Corp.
so as to become subject to the Workers' Compensation Laws. CUPANCY GROUPEEZ °C
"'L 1 20 Huntington Dr. San Marinol alit o
ADDRESS ~'
Date Applicant LFII
Lr—
NOTICE TO APPLICANT: If,after making this Certificate of ITY Ivo. q 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 USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIPanic Devices
ON
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (LIST ITEMS BELOW)
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. PARKING
SPACES REG'O D PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: O.
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S NATURE
iness and Professions Code).
ESENT USE OF BUILDING FINAL APPROVAL a
Lic.or Reg.No. Date Medi eal IBM ee
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS #c Q G Q A
ON LOT AND USE tS
O O O O
I hereby affirm that I am exempt from the Contractor's o 0 o D 0 0 0 In
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
ElI, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING Medical .
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.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE 0 0
I certify that I have read this application and state that the IN
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, 0
and hereby authorize r%ert
atives of this County to enter TOTAL FEE
u on the ab -mentiony for inspecti purposes�—
�l 1 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of P rmittee Date