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Home My Public Portal About5632 ROSEMEAD BLVD_Miscellaneous__ I _ WORKERS'COMPENSATION DECLARATION �isnn444 ' M I SC E L LA N EO U S�,A P P L I C AT I O N 'I hereby'affirm that i have a certificate of consent tself �E 875(11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurancc e,or a certified copy thereof(Sec.3800,Lab.Q. I Policy No. Company FOR APPLICANT TO FILL IN BUILDING lr/I ADDRESS Gia ' /• eeetze Certified copy is hereby furnished. XX BUILDING LOCALITY Certified copy is filed with the county building inspection LOCALITYNEAREST department. 3[y �- CROSS ST. Date Applicant NEAREST- DISTRICT NO. GROUP TYPE CBSSED BY CROSS ST. � O L � CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL G COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK rAAl} HIGHWAY STATE MAJOR SECOND LOCAL NO.OF NO. (CIRCLe) (This section need not be completed if the work involved TRACT NOW ON LOT S. USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. I } I certify that in the performance of the work for which thisj o permit is issued,I shall not employ any person in any mannekg OWNER of building kc 1AJ ® "' so as to become subject to the Workers' Compensation Laws. MA,L OCCUPANCY GROUP o ADDRESS Z3 Date Applicant IAJ NOTICE TO APPLICANT: If,after making this Certificate of CITY 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. El 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 anX Name of business O�iI� PARKING effect. • SPACES R6q'D E= PROVIDED o i License Number Lic.Class LIMITED TIME USE 11 Contractor Date � I DATE DATE I am exempt from the licensing requirements as I am a FROM. TO. INSPECTORS i licensed architect or a registered professional engineer SIZE OR NO.OF I acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S GNATURE iness and Professions Code). PRESENT USE OR BUILDING FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I 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 DI, 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 OR BUILDING h I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 1 issued(Sec.3097,Civ.Q. Lender's NameK7 ; PROPOSED MAX.OCC. 1 Lender's Address I certify that I have read this application and state that the PERMIT FEE ji; above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws re ti to building construction, and hereby r epre v of this County to enter TOTAL FEE 25.QQ upon the ab n d ty or inspection purposes. XX XX ' �to —IrSEE REVERSE FOR EXPLANATORY LANGUAGE Sig re of Pern1 to Date I I ' WORKERS'COMPENSATION DECLARATION 7SM444 . 2"08MPW12/90 MISCF.LLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LWANGELES BUILDING AND SAFETY DIVISION insure,or a certificate of.Workers'Compensation Insurance,or a certified,copy thereof(Set 3800,Lab.Q. Policy NO. Company FOR APPLICANT TO FILL—IN BUILDING ❑ BUILPJNG ADDRESSADDRESS Certified !7 copy.is hereby.furnished. J r A<.e Certified copy is filed with the county building inspection 6 •J -iAA V0 U6CALITY department NEAREST CITYZIP TC 4 Dig— 16 CROSS ST. Date Applicant SIZE OF LOT NO.OF BLOGS.NOW ON OT DPJTRICT NO. GROUP GTY PROCESSED BY >_ IL TRACT 0 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE BLOCK LOT Na. MAP HIGHWAY (This section need not be completed if the work involved NO. (CMCLLn STATE MAJOR SECOND LOCAL ASSESSOR MAP BOOK PAGE PARCEL by the permit is for one hundred dollars (S100) or less.) USE ZONE SPECIAL CONDITIONS I certify that in the performance.of the work for which thisan , LN permit is issued. I shall not employ any person in y manner 6 so as to become subject to the Workers*Compensation Laws. FADIDRkSt OCCUPANCY GROUP Date Applicant CITY ZIP z NOTICE TO APPLICANT: If. after making this Certificate ve� 0>4-f- of Exemption. you should become subject to the Workers' OCCUPANT LOAD APPLICATION F Compensation provisions of the Labor Code,you must forthwith OR EXIT HARDWARE: comply with such provisions or-this permit shall be deemed TRAILER USE 0 revoked. GEOLOGY INSPECTION❑0 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 BELOW) 9(commencing with Section 7000)of Division 3 of the Business NO.OF EXITS effect. Professions Code.and my license is in ruff force and effecor 1ness PARKING• License Number Lic.Class SPACES REQ'D PROVIDED Contractor Date LIMITED TIME USE El I am exempt from the licensing requirements as I am a DATE DATE licensed architect or a registered professional engineer FROM: TO: acting in my professional capacity(Section 7051.Business SIZE OF No.or and Professions Code). EXISTING BLDG. STORIES INSPECTO 1.5 • Lic.or Reg.No. Date PRESENT USE OF BUILDING FINAL APPROVAL 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. Business 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 7044,1 PROPOSED USE OF BUILDING Business and Professions Code), I. CONSTRUCTION CONSMUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency, for YT4 the performance of the work for which this permit is issued &_ $ (Ser- 3097,Civ.Q. PROPOSED MAX.OCC. Lender's NameAPPLICANT'I, TEL NO. Lender's Address A 0 E I - fewr P — 1 certify that I have read this application and state that the VD above information is correct. I agree to comply with an County ordinances and State laws relating to building construction,and ,PERMIT FEE r hereby authorize representatives of this County to enter upon ISSUANCE FEE the abow -mentioned property for inspection purposes. TOTAL FEE X -2 L ;, 0 _ . .. -.-,* _IL62_ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature orlqm-1 Datc