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Home My Public Portal About5624-5626 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICAC'9®N I hereby affirm that I have certificate of consent self ! COUNTY ®F LOS ANGELES BUILDING AND SAFETY DIVISION insure,or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company_ BUILDING FOR APPLICANT TO FILL IN El ADDRESS Certified copy is hereby furnished. VILDING ®p LOCALITY i DRESS 1v` ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY TE V CROSS ST. Date Applicant NEAREST G•^ 1 DISTRIC .,Vo. P TYPE PR D BY ' CROSS ST. L Tv{V� {� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS'� LEGAL ✓ c.IYrJ_ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY >- NO. - Gj (CIRCLE) STATE MAJOR SECOND LOCAL d. (This section need not be completed if the work involved NO. OF LOT USE ZONE SP CIAL CONDITIONS d P TRACT NOW ON LOT USE OF by the permit is for one hundred dollars (5100) or less.) SIZE OF LOT EX ST NG BLDG. I certifythat in the 0 performance of the work for which this �+ permit is issued, I shall not employ any person in any manner NER - LEA= �. ofir sx IU O so as to become subject to the Workers'Compensation Laws. _ OCCUPANCY GROUP LLI DDRESS Date Applicant MAIL ` ( �� crJ NOTICE TO APPLICANT: if, after making this Certificate of ITY l C TEL. O. (h 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. i ❑ ❑ No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[:] Panic Devices ❑ 'r hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS ❑ 9 (commencing with Section 7000)of Division 3 of the Busi- ••iiess and Professions Code, and my license is in full force and ' ',effect. I PARKING REO'D PROVIDED License Number Lic.Class SPACES LIMITED TIME USE Contractor Date I 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 INSPECTOR'S acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). ESENT USE OF BUILDING VACAti FINAL APPROVAL .7 7 � r-,, • Lic.or Reg.No. Date Il ib HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE '369.7P I hereby affirm that- I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- o 0 a o 88 nes:and Professions Code): NO.PARKING SPACES PROVIDED ❑ I, as owner of the property, will do the work and the 0 0 0 0 0 0 0 structure is not intended or offered for sale (Section 7044, Business and Professions Code). ` �Qy e 7. 1 5-83 'OPOSED USE OF BUILDING 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(Sec.3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. 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, an'd her y authorize representatives of this County to enter TOTAL FEE u on t abov lone roperty fginspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE igna ure o ermit e a e WORKERS'COMPENSATION DECLARATION 76M444 o cM I SC E L LA N EO lJ S APPLICATION I hereby a certificate that I have a certificate of consent tself CE 875(11-84)COUNTY OF LAS ANGELES BUYLDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,L��b. Policy No. 'u-1/3 Company BUILDING C7�� YI Y - 3FOR APPLICANT TO FILL IN ADDRESS -, // Certified copy is hereby furnished. SUILOSNG r ADDRES I n+U D wl P.ct V . LOCALITY ❑ Certified copy is filed with the county building inspection LOCALITY'�+ / p NEAREST department. (C�yr� �' C�-r 1 1 Q CROSS ST. /}S D Date Applicant NEAREST DISTRICT NO. GROUP TYPE P ESSED BY CROSS ST. CONST. /I' CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (/ d` COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY No. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF 6LDGS. (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 Lor EXISTING BLDG. }O o_ permit is issued,I shall not employ any person in any manner OWNER 8 ro i Id'' r ;-,.%so as to become subject to the Workers' Compensation Laws. MAIL `r I NG. OCCUPANCY GROUP o Date Applicant ADDRESS 1 oZ.p � ;� Dlrive PP NOTICE TO APPLICANT: If, after making this Certificate of CITY� No. BtB OCCUPANT LOAD y�y Exemption, you should become subject to the Workers' APPLICATION OR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTIONE]deemed revoked. El 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 HELOW) 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 V1c 6U.51 rr� PARK effect. VlESS-1 REO'D PROVIDED PACES License Number Lie. Class r 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 INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lie.or Reg.No. Date f O EE HOME OWNER-BUILDER DECLARATION NO. OF EXISTING ON LOT AND USE LDINGS ,1 I hereby affirm that I am exempt from the Contractor's •1 ;; ;i�ILII i License Law for the following reason (Section 7031.5, Busi- -i Iti- 9 1 111 ness and Professions Code): NO. PARKING "I" Lyi,� 4 '� I, as owner of the property, will do the work and the SPACES PROVIDED i '-°52 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 S cvZ 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 I certify that I have read this application and state that the PERMIT FEE 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 ��. QQ upon the.0pm-mentioned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 11 �L,lR3 Signature o Permitte Date WORKERS'COMPENSATION DECLARATION CE 875 M I S C E L L A N E O U S APPLICATION i CE 875 (2-80) I hereby affirm that I have a certificate of consent to c self I 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 BUILDING If ffff ADDRESS .I s ,('.- +; .✓ 1.L•e�!t%•"•�.. Certified copy is hereby furnished. BUILDING 1._+' `j f •t.. (r�' '•( y11 ''JJ LOCALITY �� ee ❑ A•DDRE85 •+�l.i i.l,n •�:�.��+1,.( +_I"\,� Lys. �` �f r ' �..,,,,.-�- �• Certified copy is filed with the county building inspection NEAREST department. LOCALITY + r. : '� � w �...4 �- I ! CROSSST Date Applicant NEAREST i r f DISTRIG.T+N O. G. UP TYPE P1�¢L` ED BY } PP CROSS ST. f 'r f ^� CONST+ Y� �J CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL • COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP J HIGHWAY .-•^*•f••'7 f,:� _ S (CIRCLE) TATE MAJOR SECOND LOCpL NO. OF BLDGS. ,r• CIRCLELU (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS J by the permit is for one hundred dollars ($100) or less.) USE of j / �- SIZE OF LOT EXISTING BLDG. �'� 'I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER 1v i so as to become subject to the Workers'Compensation Laws. JNwIL _ OCCUPANCY GROUP Date Applicant ADDRESS '��::) ✓�� ' E�rtrt:( cc ;'1�.Sft=r O V'i•} L TEL. NOTICE TO APPLICANT: If, after making this Certificate of �cITv S -I r�l . 1(~r No. OCCUPANT LOAD w 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 provision or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION ❑ deemed revoked. ClNOSpec. KnOWi.Panic Devices El INSPECTION LICENSED CONTRACTORS DECLARATION ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) I NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- nessnd Professions Code, and my license is in full force and PARKING rI�I SPACES ' REO'D L� PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date ' OATE 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 INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL RP- ,RESENT USE OF BUILDING ,�, �i�� ; Lic.or Rek.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE .q a I hereby affirm that-I am exempt from the Contractor's y; ri r :, R License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO.PARKING rr SPACES PROVIDED 1, 6 C 0"0-0 9 0 1, as owner of the property, will do the work and the structure is not intended or offered for sale Section 7044,Business and Professions Code). PROPOSED USE OF BUILDING 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(Sec.3097,Civ.C.). 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, TOTAL FEE and he by authorize representatives of this County to enter ,upon tlie•.abovF=ment�ongd^property foc,inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �} Signature of Permit ee s 1 Date