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HomeMy Public PortalAbout5629 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) M I SC E L,�A 1 Rl EO V S!APPLICATION I hereby.affirm qst I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure; ori certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN ADDRESS [ ,,,,yylI ADDRESS��p�- Certified copy is hereby furnished. DILDING S—vZ 4 -,0 e LSlI/ ADDRESSLOCALITY Certified copy is filed with the county building inspection ocwL,TYJe C j C ROSS ST.C (1 department. z Date Applicant NEAREST DISTRICT NO. GROUP ITYPE MPR CESSED BY CROSS ST. IJ V CONST.' CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ' WA 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 ($100) or less.) usE OF SIZE OF LOT EXISTIN BLDG. �••• I certify that in the performance of the work for which this o permit is issued,I shall not employ any person in any manner ho OWNER®' � _� SA^ so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP o Date Applicant ADDRESS (,.Jar, /$ 'PASO IJ el LaNOTICE TO APPLICANT: If,after making this Certificate of — C/T 93 f No J 22 _ 37 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 oI this permit shall be TRAILER USEGEOLOGY 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 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 REq'D PROVIDED SPACES license Number Lic. Class P 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 In my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES sIG uRE iness and Professions Code). h� PRESENT USE OF BUILDING C''U �Ct�/^QSI FINAL APPROVAL L!c.or Reg.No. Date (- C— T HOME OWNER-BUILDER DECLARATION NO. EXISTING BU INGS• V AN ON L T AND USE Y I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness usi Hess and Professions Code): NO. PARKING SPACES PROVIDED , Z I, 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). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency C e. 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 O O above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize represe ' es of this County to enter TOTAL.FEE upon the above- p e ty for inspection purp es. � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee !/ ate WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION I lure, o, affirm ficat I have a certificate of consent to c self COUNTY OF LOS ANGELS$ � BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING S6� �/ ��SF�ttE/=�1� ,�QL� ADDRESS LOCALITY Certified copy is filed with the county building inspection LOCALITY i7'I NEAREST department. cROS. ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P CESSED BY CROSS ST. oO -,a CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 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 (5100) or less.) USEXOF SIZE OF LOT EISTING BLDG. I certify that in the performance of the work for which this r o permit is issued,I shall not employ any person in any manner OWNER v�= BUf djor• EL7'%is/6E. Gi z/� / s� so as to become subject to the Workers' Compensation Laws. MAIL Sq�(�,Sp,r/ d�J�A496e'l. ' 40 OCCUPANCY GROUP ® t3 CD Date Applicant ADDRESS 17.p-C7-17.p-C7- e),KArf,_xve0k AA /�9,fi�/le T E L. LLL NOTICE TO APPLICANT: If, after making this Certificate of CITY �3,. g-3 9V1 NO, r�©S�-�3�5���� OCCUPANT LOAD On Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- APPLICATION F R EXIT HARDWARE: 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. Q D'r S PARKINGSPACES REQ D PROVIDED License Number Lic. Class G7/_srf•7� 7' �h LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a ROM. O: licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S acting in, my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG TORE iness and Professions Code). �y yT 7 PRESENT USE OF BUILDING FINAL APPROVAL /_/� _ Lic.or Reg.No. Date & HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �O \a ON LOT AND USE 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- I^11 �j 1321E j All 2-22 ness and Professions Code): NO. PARKING V ❑ 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 PROPOSED USE OF BUILDING ,'E'te/E44` /—�SrQ I hereby affirm that there is a construction lending agency ,// M72-feL for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name PROPOSED MAX. OCG. Lender's Address 117 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, and hereby orize representatives of this County to enter TOTAL FEE upon the ed pro or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date i WORKERS'COMPENSATION DECLARATION C E 8754(17.84) MISCELLANEOUS APPLICATION It I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANdELES BUILDING AND SAFETY DIVISION hrsure,'or a certificate of Workers'Compensation Insurance,or . ' a certified copy thereof(Sec.3800,Lab.C.). PoADDRESS (�Policy No. Company FOR APPLICANT TO FILL IN BUILDING/_� /,�j' Certified copy is hereby furnished. BUILDING �-L ^J ^ J�/�D XX ADDRESS �(r 1h r �C ( LOCALITY ECertified copy is filed with the county building inspection LOCALITY NEAREST • department. XX 1 G _1 CROSS ST. Date Applicant NEAREST DISTRICT_?W ,7UP ITYPS OC ESSED BY CROSS ST. oy CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO.OF BLDGS. (Tills section need not be completed if the work involved TRACT NOW ON LOT US ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) use OF E � G I certify that in fife performance of the work for which this SIZE OF LOT MISTING BLDG. r, permit is issued,1 shall not employ any person in any mannelkx. OWNER of building ® so as to become subject to the Workers' Compensation Laws. MAIL P I r7ftr OCCUPANCY GROUP ADDRESS 1 • O, t3d ` V S E5 Date Applicant ^ uvJ TEL. (✓ 3 OCCUPANT LOAD °- NOTICE TO APPLICANT: If,after making this Certificate of CITY OLSD Fj�-eS No. 5��9� 7� Exemption, you should become subject to the Workers' _ Compensation provisions of the Labor Code,you must forth- C? :5q&13 APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION oceuvwecr INSPECTION Panic Devices I hereby affirm that 1 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 EJ ness and Professions Code,and my license is in full force anix Name of business PARKING effect. sPAees�1d� �,� e REO*D PROVIDED License Number_ —.— Lic. Class LIMITED TIME USE Contractor— —_— Date DATE DATE El1 am exempt from the licensing requirements as I am a FROM: TOI licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGN" RE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No.__—___ Date IIONIE OWNFR-IIIJILDER 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 F11, 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 OF BUILDING 1 hereby affirm that there is a construction lending agency / c 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 y�. 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 25.00 upon the Bove-mentioned property for inspection purposes. : XX (�� �` XXq (� (�� SEE REVERSE FOR EXPLANATORY LANGUAGE tiinn,r„ ,.I'14 nnirl•• h;Ilr` WORKERS*COMPENSATION DECLARATION 76M444 - ��IISCELLANEOUS APPLICATION CE 875 (1184) r`� I hereby affirm that I have a certificate of consent to self � 1 Insure. or a certificate of workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION I a certified copy thereof ISec.3800.Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN ADDR NG5426 o /)_Ce ` /� / ADDRESS ` 1 107 Certified copy is hereby furnished. A..Ress 629 Al, WCAMEA 414.0• LOCALITY ice* J4 D I Certified copy is tiled with the count} building inspection LOCALITY NEARESTIL department. Temple City cRoss ST. Date Applicant ' NEAREST n //�� DISTRICT NO GR UP TYPE CESSED BY • CROSS ST. J79 � y /� � CO CERTIFICATE OF EXEMPTION FRONI'•�'ORI:ERS' LEGAL / (/ COMPENSATION INSURANCE 1: DESCRIPTION LOT NO. IBLOCK )MAP HIGHWAY I No.NO. OF BLOCS. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not lie completed if the work involved ! -RacT NOW ON LOT USE %ONE SPECIAL CONDITIONS by the permit is for one hundred dollars 6100) or less.) u9E of SIZE OF LOT EXISTING BLDG, t I certify that in the performance of :lie'.York for which -his - permit is issued. 1 ,(tall not employ any<u -ie:soj :. anner OWNER so as to eco a b�ect to tate Workers'• pensation aws. OCCUPANCY GROUP -_ MAIL 20 Loc.; PI I Date a7 Applicapr� ADDRESS Sa y NOTICE TO APPLICANT: if. after makin_• :.t s .Lr,ificate lit $i CITY �e �� NE lbvJ y 19-1� OCCUP.4N-LOAC Exemption. you iliould become oubiecr :o :lie Workers' 4PDLICA�ICN c'�R .X IT H.4RCI.VAI=E Compensation provisions of the Labor Code. you must torth- with comply with 4ucli provis:ons or :lits ^ermtt shall be -RAILER LISE n GEOLOGY INSPECTICN No Spec. Kno%•vi. El deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$$ i hereby affirm :hat I am licensed under provisions of Chapter SAFETY PERMIT 11 (LIST ITEMS BELOW) 9 (commencing with Section 000) of Division 3 of the Busi- LJ NO. OF EXITS ness and Professions Code. and my license is in fall force and a effect. PARKING SACES REO.O I PROVIDED P o t License Number Lic. Class LIMITED TIME USE y Contractor Irate— _ DATE DATE N W N 1 am exempt from the licensine requirements :LS I am J ro: D ( licensed architect or a registered professional engineer ;IZE of vo. of INSPECTOR'S Z actln� in my pTOf CSSional mr.aiirL Sd;:io;t -1151. BII S- EXISTING BLDG. STORIES SIG TURE a inessa;td l':gizssicnxl:idol. FINAL APPROVAL O PRESENT USE OF BUILDING r : ULis.or Ree. No. Date , X ! _ri 6 .7 HOME OWNER-BUILDER DECLARATION NO. OF EXIUSESTING BUILDINGS ND I hereby affirm that I am exempt from rite Contractor',; ON LOT A I License Law for the following reason (Section -031.5. 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 I 704.1.Business and Professions Code). CONSTRUCTION LENDING AGENCY X' PROPOSED USE OF BUILDING I hereby affirm that there is a construction lendine aecriev Save STVQF Rg QET,4 ! For lite performance of the work for which this permit is L� 5�0�� issued(Sec. 3097,Civ.C.). S Lender's Name PROPOSED MAX. OCG. Lender's Address 1 1 certify that 1 have read this application and State that lite PERMIT FEE 25.00 above information is Correct.I agree to Comply with all County ISSUANCE FEE ordinances and State laws relating to building construction. turd hereby authorize representatives of this County to enter I TOTAL FEE 25.00 ! upon the ab - en t roperty for ins�;;oses. SEE REVERSE FOR EXPLANATORY LANGUAGE : L Signature of Permit ee Date