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Home My Public Portal About5628-5628 1/2-5632-5632 1/2 ROSEMEAD BLVD_Miscellaneous__ WORKL'RS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I Luraffirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, , o or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING - ADDRESS L� Certified copy is hereby furnished. V BUILDINGf 6s-em � U M LOCALITY ` ADDRESS (o Certified copy is filed with the county building inspection V LOCALITY p �,�� 1- C•+ ��• NEAREST department. (� ceoss ST. Date Applicant y NEAREST DISTRICT NO. GROUP TYPE O ESSED BY CROSS ST. CT. t CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION L07 NO. BLOCK MAP1&6NC IR C LEIC Nw Av) STATE MAJOR SECOND LOCAL � NO. OF BLDGS. NO.� (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 (/J ZZ `�V a I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. e permit is issued, I shall not employ any person in any manner OWNER r Sf�L NL' . S' so as to become subject to the Workers' Compensation Laws. MAIL n OCCUPANCY GROUP o Date Applicant ADDRESS f�i�� I�ljfJ �4! p(y X(`(V v TEL. L" NOTICE TO APPLICANT: If, after making this Certificate of CITY 5'111V M1112TfJo 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. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ 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. PARKING SPACES REO•D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF FROM. TO. 01NPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES GNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING O Lic.or Reg.No. Date C. HOME OWNER-BUILDER DECLARATION NO. 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 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). CONSTRUCTION LENDING AGENCY "'�S PROPOSED USE OF BUILDING I5(q\1 f r C- I hereby affirm that there is a construction lending agency Qw1 r O S aeh we for the performance of the work for which this permit is ;l 7 2 a Q A issued(Sec.3097,Civ.Q. Lender's Name # D o o D 8 8 PROPOSED MAX. OCG. Lender's Address o o 0 o 0 0 0 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 1 ' �l 0 619-87 Ord' noes and State laws relating to building construction, �d and11 re uthorize representatives of this County to enter TOTAL FEE aLj' xj up. ab ve-mentioned propert fo spection purposes. C, T t 7 SEE REVERSE FOR EXPLANATORY LANGUAGE �I 7 Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPL1CATION I hereby affirm that 1 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.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDIARESS NG 5628 N. Rosemead B1.Va. LOCALITY D Certified copy is filed with the county building inspectionNEAREST department. A O LITY CROSS ST. Date Applicant EAREST STRICT NO. GROUP TYPE PROCESSED BY CROSS ST. Between Las Tunas & Broaaw $I CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY—_ IGHWAV 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.) USE of SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this 71 permit is issued, I shall not employ any person in any manner OWNER ReriSaC Inc. so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP /j'- o A DRESS 1 V T Date Applicant Sari Marino NO. 282-8443 OCCUPANT LOAD I„ EL' NOTICE TO APPLICANT: If,after making this Certificate of CITY y Exemption, you should become subject to the Workers' z 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 E]deemed revoked. 1:1E] No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIO Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PER IT ❑ LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- No, of Exlrs ness and Professions Code,and my license is in full force and effect. PARKING REq'D O PROVIDED D SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a PROM: 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 Z/ PRESENT USE OF BUILDING � Lic.or Reg.No. Date (/ 9 HOME OWNER-BUILDER DECLARATION NO. 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 7031.5, Busi- ness and Professions Code): NO.PARKING ❑ 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section p 7044,Business and Professions Code). O #0 0 a r5 �� CONSTRUCTION LENDING AGENCY �`� ' PROPOSED USE OF BUILDIN�1G ��V)z�,�p�C ° I hereby affirm that there is a construction lending agency 5HVe mote SA 1,91ZIZ �' �\^\ 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, ^ Ail and hereby authorize representatives of this County to enter TOTAL FEE p( IUV upi 6 the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per ttee Date N. WORKERS'COMPENSATION DECLARATION I CE 875(1 1-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,'or a cer if�te of Workers'Compensation Insurance,or a certifiCu"copl thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TOFILL'IN BUILDING r- Q ADDRESS 20 Certified copy is hereby furnished. )( BUILDEING LOCALITY '` ADDRSS 0 Certified copy is filed with the county building inspection r LOCALITY NEAREST department. X /� C% CROSS ST. Date Applicant NEAREST V DISTRICT NO. GROUP TYPE OCESSED BY CROSS ST. CgrD(/, -) CO CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL d' COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. OF BLDGS. NO. (CIRCLE) (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 . a I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG permit is issued I shall not employ person in p p y an y p any manner OWNER ACa r, :In s' so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP -� o 8 Date ADDRESS EApplicant O_ TEL. OCCUPANT LOAD w NOTICE TO APPLICANT: If,after making this Certificate of CITY No. vJ Exemption, you should become subject to the Workers' z 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 GEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 1:1Panic Devices El I hereby affirm that I am licensed under provisions of Chapter q TY PEt1MI 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. C V �' PARKING REQ'D pROVID ED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE DI 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). PRESENT USE OF BUILDING FINAL APPROVALL� ` Lic.or Reg.No. Date l� HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �Iri� v r li 37 1 !ski 9: ON LOT AND us. J -�'�-;`(^i I hereby affirm that I am exempt from the Contractor's /�'�) T-.94 •# PO 5:-`I 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 AGENCYPROPOSED USE OF BUILDING Mal IAY:tqI 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 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 upon t}ie a e-menti ed property for inspection purposes. •,./ SEE REVERSE FOR EXPLANATORY LANGUAGE 11" v 'A Signature of Perm t Date