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Home My Public Portal About5633 ROSEMEAD BLVD_Miscellaneous__ 11'URI:I.IiS'('ODIPI:NSA'1'ION DECLARATION CE 875(11.54) M ISCELLANEOUS�APPLICATION 1 11e;aby 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.C.). Policy No.--- - --Company FOR APPLICANT TO FILL IN Certified copy is hereby furnished. BUILDING XXADDRESS LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. XX �O�l� ei O CROSS ST. Applicant___--_ NEAREST DISTRICT NO. GROUP CONST.TYPE P ESSED BY CROSS ST. Q�j CERTIFIC'A'TE OF EXEMPTION FROM WORKERS' LEGAL aee C'OIIIPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP MAHIGiRCL Y STATE MAJOR SECOND LOCAL NO.OF BLOCS. (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. 9-3 O I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manneilEX OWNER of building D- so is In heroine subject to the Workers' Compensation Laws. MAIL '— OCCUPANCY GROUP c� ADDRESS C- Applicant— — �� . . OCCUPANT LOAD R tiJ NOTICE 1"0 APPLICANT: If,after making this Certificate of CITY NO �L%,�LILU� No. Exemption, you should become subject to the Workers' '- C'ompensation 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❑ No Spec. Knowl, El deemed revoked. OCCUPANCY INSPECTION❑ Panic Devices LICENSED CONTRACTORS DECLARATION I hcreb) affirm that I am licensed tinder provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW 9 (commencing with Section 7000)of Division 3 of the Busi- NO.OF EXITS ncss and Professions Code,and my license is in full force art X Name Of b SineSS PARKING �t CffCCI. REQE= PROVIDED 1 — 1 SPACES ll-- J License Number-- _Lic. Class LIMITED TIME USE Contractor. - -- -__-- - - -_--Dale --- DATE DATE FROM: TO: El1 :un exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF SIGNATURE INSPECTORS acting in my professional capacity (Section 7051, BUS E%ISTING BLDG. STORIES iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING •�"zJ'�W L3 Lic.or Reg.No._._—.__ _Date HOME DECLARATION No. oil EXISTING BUILDINGS ON LOT AND USE I hereby affirm that 1 am exempt from the Contractor's 4769 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 i SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I 1 hereby affirm that there is a construction lending agency h'or the performance of the work for which this permit is issued(Sec. 3097,('iv.C.). Lender's Nannie-- --__-•_-•___-- PROPOSED MAX OCC. I A Lender's Address —-_. _- __ _——___ -- PERMIT FEE 1 certify that I have read this application and state that the 1 5.00 * above information is correct.1 agree to conmply with all County ISSUANCE FEE ordinances and State laws relating to building construction, 4 and hereby authorize representatives of this County to enter 1 TOTAL.FEE 25-00 on the aboveAnenti ned pr petty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ _ /� XX j{ Ci!•II:IIIu !! rnuillrr Da Ie f' ) WORKERS'COMPENSATION DECLARATION 276M444 .000 3DPW72/90 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING AND SAFETY DIVISION insure,or a certificateof.Wdrkers'Compensation Insurance,or a certified copy thereof(Set.3800, Lab.C.)• (� Policy No. Company FOR APPLICANT TO FILL.IN BUILDING • ' BUILDING ADDPFSS r ADDRESS ❑ Certified copy,is hereby:famished. X ^f 3 ov-..l�ei(•f7 V � �' el ?j ( LOCALITY { I ❑ Certified copy is filed with the county building inspection elr � �� ZIP �� 7dtJ I department. / NEAREST dt , CROSS ST. Date '' ' = Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CONST. a CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO. Q ( I MA COMPENSATION INSURANCE NOP C1GHWAY RCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars NI 00) or less.) �9- ( I certify that in the performance.of the work for which this rGrZ r TEL Ng p /rf tV permit is issued. I shall not employ any person in any manner 5 so as to become subject to the Workers' Compensat S. ADOREss �i � OCCUPANCY GROUP � ( I Date , d Z Applicant./hi�/� CITY�O/ L�� ZIP NOTIC�PPLICANT: If. after making this Certificate OCCUPANT LOAD of Exemption. you should become subject to the Workers' APPLICATION FOR Compensation provisions of the-labor Code,you must forthwith EXIT HARDWARE: comply with such provisions or-this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ t revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[$ Panic Devices ❑ i I hereby affirm that I am licensed Under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) t I 9(commencing with Section 7000)of Division 3 of the Business gm—e O us ess NO.OF EXITS and Professions Code,and my license is in full force and effect. ? PARKING• REWDD PROVIDED D License Number Lie Class �d� SPACES ( I I Contractor Date LIMITED TIME USE i ❑ I am exempt from the licensing requirements as I am aFROM: TO:DATE DATE licensed architect or a registered professional engineer { acting in my professional capacity(Section 7051,Business SIZE OF /,� S' NO.OF INSPECTOR'S E and PIOfeSS10n5 Code). EXISTING BLDG. Z ( STORIES SIGNATUR . Lie or Reg.No. - Date PRESENT USE OF BUILDING 9-M-14.- FINAL APPROVAL � i QZ i 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 { ' I Professions Code): NO.PARKING i El 1. as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale(Section 7044.2 PROPOSED USE OF BUILDING Business and Professions Code). I CONSTRUCTION LENDING AGENCY j 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.). PROPOSED MAX.OCG Lender's Name APP -NT( V% Lender's Address ADDRESS. C g17 i I I certify that I have read this application and state that the re above information is correct I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and - hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inspec' rpose - I:s TOTAL FEE ~ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature or Permittee Date I ! WORKERS't;C?Ml'hiv,1ii°tttutN uct,LHtSHtivtt 20-0063oPwii/90 Irs•�•� ••C,,L,.,L.K)<�1Gi..lV� .H.�d—1...R%.►rlk It .i%.0 It lIl I hereby'affirm that I have,a certificate bf consent to self COUNTY OF LOS"ANGELES - 'BUILDING AND SAFETY DIVISION 4insure,or a certifiaatii oLWtifkars'Compensation Insurance,or a certified copy thereof(Set~3800, Lab.C.). - ':_._. Pollcy'No. Company FOR APPLICANT TO FILL IN BIiILOING I ❑ Certified c0 BUILDING.ADDRESS ADDRESS Py.is hereby famished g 3 3 'IV (,�,� . dO 84 b;? LOCALITY I :' ❑ Certified copy is filed with the county building inspection CITY ZIP .. i department72. /�1L� �� Cj�/�� NEAREST. Applicant r CROSS ST. Date '' 'rs"' SIZE OF LOT 'WO- SLOGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY }' CEMIFICATE"OF EXEMPTION FROM WORKERS' coNST. I COMPENSATION INSURANCE TRACT BLOCK LOT NO. MAs NIGNwwY U NO. (CIRCL.CI STATE MAJOR SECOND LOCAL.. ('This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL I by the permit is for one hundred dollars ($100) or less.) USE ZONE SPECIAL CONDITIONS ' y Fg= Owner TEL NO. L certify that in the performance.of the work for which this permit is issued'I'Shall not employ'any person in any manner L4 YQ.2 i r 0 310 $'3j/7sc< so as to become subject to the Workers' Compensation Laws. ADDRESS , G-Ya z I a 1 r3 ZA V&5rM N T c4).sf N P,C, �.f4pOCCUPANCY GROUP Date Applicant . CITY zIP NOTICE TO APPLICANT: If; after making this Certificate �� R ANC 90 S-0?_ OCCUPANT LOAD of Exemption. you should become subject to the Workers' APPLICATION FOR Compensation provisions of the-kalior Code,you must forthwith EXIT HARDWARE: comply with such provisions or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ revoked No Spec.Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[ Panic Devices ❑ i I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (UST ITEMS BELOwi t 9(commencing with Section 7000)of Division 3 of the Business' Bus @SS NO.OF EXITS and Professions Code,and my license is in full force and effect game cit I License Number LitClass PARKINGSPACES REO'D I I PROVIDED 1 I Contractor Date LIM TTED TIME USE 1 I El I am exempt from the licensing requirements as I am a RATE DATE licensed,architect or a registered professional engineer FROM: To: acting in my professional capacity(Section 7051,Business SIZE OF NO.OFINSPECTOR'S and Professions Code). EXISTING BLDG. STORIES SIGNA RE. J:i4Lic or.Reg No. - Date PRESENT USE OF BUILDING FINAL APPROVAL p, I HOME OWNER-BUILDER DECLARATION 1 NO.OF EXISTING BUILDINGS • I 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 - I, as owner of the property, will da the work and the SPACES PROVIDED. ! structure is ndt intended or offered for sale(Section 7044,1 PROPOSED USE OF BUILDING dry Business and Professions Code). r 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 t ?' (See.3097,Civ.C.). PROPOSED MAX.OCC, I Lenders Name APPLICAN 1pJf3(M � TEL NO. s�� Lender's Address ADORE TILS P.�DI S. I certify that I have read this a � � pplication and state that the • above information is correct I agree to comply with all County PERMIT FEE I ordinances and State laws i-elating"to building construction,and hereby authorize rtipresentatives.of this County to enter upon ISSUANCE FEE ¢� the above-me tion property for inspection purposes t - - r• I �• TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P mitte Date