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Home My Public Portal About5623 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(1 1-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate o£ 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. CompanyFOR APPLICANT TO FILL IN BUILDING i ADDRESS Certified copy is hereby furnished. BUILDING ' LOCALIT ADDRESS Certified copy is filed with the county building inspection LOCALITY g'L Liz- NEAREST department. . - JGQ� cRoss sr. Date Applicant NEAREST DISTRICT NO. GR UPTYPE P CESSED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF BLDGS. (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 � SIZE OF LOT EXI TIN BLDG. G_ 9:I certify that in the performance of the work for which this cru o permit is issued,I shall not employ any person in any manner OWNER _ so as to become subject to the Workers' Compensation Laws. MAI .Q OCCUPANCY GROUP a - - O v Date ADDRESS Applicant LIJ NOTICE TO APPLICANT: If, after making this Certificate of CITY L S�f NO - OCCUPANT LOAD 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. Know[. deemed revoked.' Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ 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 ppqq �( I I effect. 1�4L VLJ `I C+ PARKING SPACES RHQ'D PROVIDED License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO.OF IN acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. r STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �J ,`I I hereby affirm that I am exempt from the Contractor's ON LOT AND USE :q. License.Law for the following reason (Section 7031.5, Busi- j, / l,jiiJl —ik�la ;- ness and Professions Code): NO. PARKING Y� 4-7-7'1 ,u; �, I, as owner of the property, will do the work and the SPACES PROVIDED !i 3 I-I•13= 5 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a constmction 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 I certify that I have read this application and state that the PERMIT FEE GU _ above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE VU upon the above-mentioned property for inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE .( -;,-- Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION {� CE 875 Lt I hereby affim that I have a certificate of consent to self COUNTY OF LOS ANGEVES BUILDING AND SAFETY DIVISION insure, or a cerrtificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS !� � Certified copy is hereby furnished. .U'LDIN Z + , LOCALITY FCertified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GR UP TYPE PR CESSED BY CROSS ST. CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Y COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NIC HWwv STATE MAJOR SECOND LOCAL NO. OF BLDGS. NO. (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG, rf+ I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any mannerOWNER d"_r a d jr 1;— so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP - o V ADDRESS ~ Date Applicant /" L�IJ NOTICE TO APPLICANT: If,after making this Certificate of clr zdg� p NOL �- _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 oI this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices E I hereby affirm that I am licensed under provisions of Chapter FETY 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 MIME � }� ' effect. MI Gr S�� r PARKING JQ�' SPACES REQ'D D PROVIDED License Number Lic. Class ''`'/As '�" LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM: O: licensed architect or a registered professional engineer SIZE OF � NO.OF / INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. V, STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING y Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's 5/ 6/5-1 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING AN :I El1, 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 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 I certify that I 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, .n l and hereby authorize representatives of this County to enter TOTAL FEE U"' upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 6 �v ure of Per tee D Aft %%PRKERS'COMPENSATION DECLARATION 76M444 ' r CE 876(2-80) WSCELLPVNEOUS/ APPUCATION I• hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES 6UIILDIING AND SAFETY DIVISION i?I or a certificate of Workers'Compensation Insurance,Ile a certified copy thereof(Sec.3800,Lab.C.) /_N Policy No. 41 Company FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy,is hereby furnished. ZAD LDINGRESS a LOCALITYCertified copy is filed with the county building inspection Zee LOCALITY NEAREST department. CROSS ST. (CQ/ Date Applicant NEAREST A DISTRICT NO. ROUP TYPE / 11RIC SED 1BY CROSS ST. � i (� rJ CONST. /p// - CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Q 6� COMPENSATION INSURANCE DESCRIPTION LOT NO �' BLoc.K MA HIGHWA NOP ';L (clRe E) STATE MAJOR SECOND LOCAL } (This section need not be completed if the work involved I F1 C NO. OF BLDGS. O P TRACT J NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) I IND ��3 V I certify that in the performance of the work for which this i SIZE OF LOT Ex IS. a G. permit is issued, I shall not employ any person in any mannerO NER o so as to become subject to the Workers'Compensation Laws. I MAIL 1 OCCUPANCY GROUP .� U ADDRESS .'C C W Date Applicantr� CL NOTICE TO APPLICANT: If, after making this Certificate of , CITY ITvo� JO OCCUPANT LOAD 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 E] GEOLOGY INSPECTION ❑ deemed revoked. I ❑ No Spec. KnOWi.Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION�( I hereby affirm that I am licensed under provisions Of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code, and my license is in full force and t effect. I lcant s Name - Qa( RKING ACES ' REq'D D PROVIDED D License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO:Phone - 2/� 3 /rJ I am exempt from the licensing requirements as 1 am a. ��' 6 licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting In my professional capacity (Section 7051, BUS- 1, EXISTING BLDG. 6�� STORIES SIGNATURE iness and Professions Code). I EsENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date i HOME OWNER-BUILDER DECLARATION NO.OF ExIsTiNGAVIJILDINGS ON LOT AND Us , I hereby affirm that, I am exempt from the Contractor's Al 7J 9 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED # 0 0 0 0 140 I, as owner of the property, will do the work and the ' structure is not intended or offered for sale (Section I _ o D a D D o o 2 7044,Business and Professions Code). ROPOSED USE OF BUILDING O Q 5_8 O CONSTRUCTION LENDING AGENCY 1 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 ftrtify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinancesand State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter i upon the above-mentioned property for inspec 'on purposes. SEE REVERSE FOR E&PLANATORY LANGUAGE Signature of Permittee �, Date WORKERS'COMPENSATION DECLARATION 76nn444 MISCELLANEOUS, A P P L I C A T I O N i ilere;y affirm that I have a certificate of consent to self CE 875(11-84) � I I insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION iLJ a certified copy thereof(Sec.3800,Lab.Q. i Policy NO. Company BUILDING FOR APPLICANT TO FILL IN ADDRESS (/J Certified copy is hereby furnished. BUILDING 0 -�✓�� L L, k.ALITY ADDRESS .) Certified copy is tiled with the county building inspection NEAREST LOCALITY department. Temple City CROSS ST. Date Applicant NEAREST DISTRICT NOrr 7P ITYPE CESSED BY CROSS ST. �t y CON CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL '(/o COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. CIRCLE) STATE MAJOR SECOND LOCAL ( NO. OF BLDGS. (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.) SIZE OF LOT USE OF I certify that in the performance of the work for which this EXISTING BLDG. �~ I permit is issued,I shall not employ any person in any manner OWNER ��Z f NO so as to become subject to the Workers' Compensation Laws. — MA ILD ,7� OCCUPANCY GROUP ADRESS ;YJ Date Applicant T . r NOTICE TO APPLICANT: If,after making this Certificate of CIT�W C--1EIZIU-0od NOEL. 3 (�. _Q At6- OCCUPANT LOAD ' 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. P LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONU Panic Devices ❑ ` I I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT (LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING SPACES REO•D D PROVIDED D License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSP C OR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI TUR iness and Professions Code). FINAL APPROVAL t PRESENT USE OF BUILDING Lic.or Reg.No. Date f I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS (' Gr ON LOT AND USE 1 hereby affirm that 1 ant exempt from the Contractor's (y/ %J License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING I, 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). p CONSTRUCTION LENDING AGENCY g PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency VI for the performance of the work for which this permit isZ. issued(Sec.3097,Civ.Q. Lender's Name t�I PROPOSED MAX. OCC. I--) Lender's AddressI� PERMIT FEE � I certify that I have read this application and state that the 25.00 above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE --+ I 25.00 upon the above-mentiony4 pro pert f insp ction purposes.' 11 SEE REVERSE FOR EXPLANATORY LANGUAGE i =r, ' I t Signaure of Per a Date - nJ I - ,..I I I 1 WORKERS*COMPENSATION DECLARATION a CE87s ��1•aal MISCELLANEOUS APPLICATION su 1 herebv affirm that I have a certificate -if consent to self insure. t)r a certificate of Workers"Curnp•:nsation Insurance.or COUNTY OF LOS .ANGELES BUILDING AND SAFETY DIVISION ; a certified copy thereof(Sec.3800.Lab.C.I. Policy No. _Company FOR APPLICANT TO FILL IN BUILDING A DDRESS Certified cap} is hereby furnished. BUILDING �• t)� 1��i u D. / ADDRESS �- LOCALITY I EjCertified copy is filed with fife catlnt% bUlldlne Itl.,pl•L'IIOII LOCALITY NEAREST department. Temple City CRoss ST. Date applicant NEAREST D15�=CT NO, GAOUP CO CESSED BY CROSS ST. T / CO CERTirIC ATE OF EXEMPTiON FROM WORKERS' LEGAL 1 r/ e! I COMPENSATION INSUR��C 1-: � DESCPIPT:ON LOT NO. �BLOCK I MAV wta Nw Ar yp. STATE MAJOR SECOND LOCAL 1 NO. OF SLOGS. (CIRCLE) (This section need not be complered If the Mork Involved -RAC- NOW ON LOT USE ?ONE SPECIAL CONDITIONS by the permit is for one hundred dollars 61001 or less.) USE OF l ' 1 certify that in the performance of -he•.��.1r4- foe which -his SIZE OF LOT EXISTING BDG. permit is issued. I shall not employ an} �e:son :n any manner OWNER S , LA so as to become subject to the Worker%' Compensation 1_aws. HAIL OCCUPANCY GROUP ADORE S Date Applicant NOTICE TO APPLICANT: If.after makine :his Certificate -it gl CIT' � vc '�6a6)�6_�l b l ll OCCUPAN-LOAC Exemptio•1, you <hpald become itibiect :c, -he Worker;' Compensation oro:•isions of-lie Labor-.'.)da. you :oust forth- 4POL!CATIC'l °?F .Xf-yn�r�yat=E I with compiv ivith <ucit provisions or his -erntit ,hail be -RAILER USE GEOLOGY :NSPE CT:CN — 1 deemed felQked. _ No Soec. :lo%vl. Li LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$$ Panic Devices i hereby affirm -.hat I am licensed under previsions of Chapter SAFETY PERMIT PERMIT (LIST ITEMS BELOW) 9 icommencine with Section ?000) of Division 3 at lite Buri- No. of EXITS ness and Professions Code.and my license is in :till farce and effect, PARKING REO O O PROVIDED D SPACES License Number_ Lic. Class LIMITED TIME USE U) Contractor Date W —_ DATE GATE w El I am exempt from Elle licensing reauirements as I am .I `"M• re: m 1 licensed architect or a re_sistered oro essional engineer 31ZE OF VO. INSPEC Z acting in •fly pre eSilonal :aC1::li' Se.-.ion 'fl:i. BUS- EXISTING BLDG. STOROFIES SIGN R Uinessand Pruics.,icnsladel" DFINAL APPROVAL Lie.or Re No .t:c "RESENT USE OF BUILDING ^ �Ur HOME 0%1N1711-BUILDER DECLAR.%rm NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's i License Law for the following reason ISectiun -1131.. Busi- ness and Professions Coder: NO. PARKING 1, as owner of the property, will du the work and the SPACES PROVIDED structure is not intended or offered for cele ISectiun I 704.4.Business and Professions Code). CONSTRUCTION LENDING AGENCi' X PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency a',l I for the performance of the work for %hick Illi., permit is issued(Sec. 3097.Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address I I certify that I have read this applic-ation and state that the PERMIT FEE 25.00 above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws rclatine to building construction. and hereby authorize representatives of this County to enter TOTAL FEE 25.00 ! upon the aero e-mentioned property for inspection purposes. 1 SEE REVERSE FOR EXPLANATORY LANGU%GE 4 �- Q. �V Sienature o ermitt a Date I