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HomeMy Public PortalAbout5636 ROSEMEAD BLVD_Miscellaneous__ rWORKERS:COMPENSATION llECLARATION ' CE 875(2-80) 7610444I t' MISCELLANEOUS APPLICATION I h�rebyaffirm that I have certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION irt+)ure, or a certificate of Workea rs'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ❑ ADDRESS Certified copy is hereby furnished. ILDI SS IAV NG S V & c,s e iA0 d/ �l 1 LOCALITY DRE Certified copy is filed with the county building inspection DEAREST / department. LOCALITY crxoss ST. I Date - Applicant NEAREST DISTRICT NOJ ROUP TYPE PROCESSED BY CROSS ST. V or-is-r. /'/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a v COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK MAP /HIGHWAY >_NO. F BLDGS. y0. ©� Y(CIRCLE) STATE MAJOR SECOND LOCAL a I (This section need not be completed if-the work involved I TRACT NOWOON LOT UiSE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. 3 tr I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner fORESS ER f� Ul — 2 0 so as to become subject to the Workers' Compensation Laws. L OCCUPANCY GROUP //(� W I tL Date Applicant ZNOTICE TO APPLICANT: If, after making this Certificate ofY Nol. OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLI ATION FOR EXIT HARDWARE: with comply with Such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION ❑ deemed revoked. C1NOS Spec. Kt10Wi. ❑ Panic Devices OCCUPANCY INSPECTION LICENSED CONTRACTORS DECLARATION ❑ I hereby affirm that I am licensed under provisions of Chapter I SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code, and my license is in full force and PwRKING. effect. REQ'D PROVIDED SPACES License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE OFROM: 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 SIGNATURE mess and Professions Code). ESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS A 4 5 3.7 A ON LOT AND USE G I hereby affirm that- I am exempt from the Contractor's o D D o 4 0 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 1 SPACES PROVIDED 0,0 0 0 0 0 0 2 I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section ; 03,26-81 7044, Business and Professions Code). i PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency I YV! Cti 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, oe TOTAL FEE and hereby authorize representatives of this County to enter on the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ; Signature of Permittee Date I WORKERS'COMPENSATION DECLARATION I 76M4I CE 875(2-80) MISCELLANEOUS AIrQ""LICATION I hereby affirm that I have a certificate of consent to self COUN'T'Y OF LOS ANGELES BUILDING AND SAFE'T'Y 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 ADDRESS 3 ❑ Certified copy is hereby furnished. BUILDING SS OC gLITY ❑ DR' Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. DateApplicant NEAREST � DISTRICT NO. GROUP I T PROCESSED BY CROSS T. CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL `� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NIGH WAY NOI (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved NO. OF BLDGS. P TRACT NOW ON LOT UST ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF U SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this v M permit is issued, I shall not employ any person in any manner ,.1 0 so as to become subject to the Workers'Compensation Laws. w LER �ONGb OCCUPANCY GROUP DRESS LU Date Applicant k;;� L NOTICE TO APPLICANT: If, after making this Certificate of TTY G NOL 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 SUCK provisions or this permit shall be TRAILER USE[] GEOLOGY INSPECTION ❑ deemed revoked. NOSeC. KnOWI.❑ P Panic Devices El LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code, and my license is in full force and PARKING 'D I I D e 'oct. J SPACES REOPROVIDED License Number Lic.Class 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- ISTING BLDG. STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING �i Gff� FINAL APPROVAL ll_�?i Lic.or Reg.No. Date or L� g 6--f—I NO.OF EXIS HOME OWNER-BUILDER DECLARATION TING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's 768.7A License Law for the following reason (Section 7031.5, Busi- 0 0 o D 88 ness and Professions Code): NO. PARKING SPACES PROVIDED Ell, as owner of the property, will do the work and the o o a 0 a D o structure is not intended or offered for sale (SCLtiOR Of 7044, Business and Professions Code). Is ROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 10 I hereby affirm thatr 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, and hereby authorize representatives of this County to enter TOTAL FEE o bo'e-mentionoperty for in6spection purpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE Signa t re of Permittee Date �C WORKLRS' ('OMPLNS.AIIQN UI:('LAR:\ZIONM15ULLLANEOU5 APPLICATION ..I;utA•..I�I':•n.• till . I I hereby affirm that I have it a a etil'ieale of consent Lti +eh COLIN'l l' OF I.OS ANGELES 131111-DING AND SAFETY DIVISION I� I insure,or eerlificate til' Workers*CmilPen,aiitin In+ur•ulee,or I it certified copy thereof (Sec. 3800. lab. U.) Policy No. - • Company FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRESS y ADDRESS ❑ Certified copy Is hereby fu I' BUILDING - ���6 I�q� e {J� LOCALITY ❑ Certified copy is filed %%ith Lhc county huildiny In,pretiun CITY„ ) ZIP--- --�7 •-� department. 1 QAL � IL1 t I a O NEAREST l¢ f/� CROSS ST. Date Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CONST. I (ER"1ll•I('AII: OF EXIM11ION I•R(M1 \\�0RKI.RS* ---- C'OMPL-NSAI7()N INSURANCE TRACT BLOCK LOT NO. hlAp — HIGHWAY (• I.O. (CIRCLED STATE MAJOR SECOND LOCAL (This section need not be completed if Illy nork illlolled ASSESSOR MAP BOOK PAGE PARCEL 115E ZONE SPECIAL CONDITIONS I- by the permit is for one hundred dollars 11.41001 or Ic%s.) — ; OWNER TEL NO. 1 certify that in the perlirrnuutce (it' Ihr tturl� Ihl lthleh this --- -L_ ( permit is issued. 1 shall not employ ;ut) Prl+on nl .uly nl.ulner 1 so as to become subject to the Workers' Compcn,aliuit la"% ADDRESS OCCUPANCY GROUP 1 Date _ Applicant CITY ZIP NOTICE TO APPLICANT: 11', alter making this Certificate OCCUPANT LOAD of Exemption• you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code.)Oil must litnhwith I--� comply with ~dell pro\inions lir this Pel•Illlt Shall lie deellled TRAILER USE LJ GEOLOGY INSPECTION revoked. No Spec.Know). ❑ OCCUPANCY INSPECTIONN Panic Devices ❑ ' LICENSED C'ONTRAC`TORS DL('LAR.\IIt)V 1 hereby affirm that I aln IICenSfd tllkler provisions til ( I1:IPler SAFETY PERMIT IJ ILI T ITEMS BELOW. vI I 9(commencing with Section 7000)of Di%ision 3 of the Business I r7 NO.OF EXITS L and Professions Code,and my license is in Bill three and effect. PARKING• t ' PROVIDEDIic. REQ*DLicense Number D O I Contractor Date - -- -- -- -- -- - — -- LIMITED TIME USE DATE DATE I ❑ 1 am exempt from the licensing requirements ;t.% 1 am a FROM: TO: licensed architect or it registered professional engineer acting in my professional eapacit) (Section 7051, 1111+tiles+ SIZE OF NO.OF INSPECTOR'S I iEX IS rING BLDG. STORIL S SIGNATURE tool I'rulessions Code). -- ----_--- --- Lie.or Reg. No. Dale PRESENT USE OF BUILDING FINAL APPROVAL ( /L 13� I - — -_--Y_• 5a 0 V7 - ---- IIOML' OWNER-13UILDI_I( DL( 1.:\R.411ON •Nu.Or 1,Xh lING BUILDINGS ON LOT AND U!.E 1 hereby affirm that I atm wwnlpi from the('untracior'+ I Igen%e -— --------- -- --- Law for the folltming reason (Section 7031.5, Business and _ 1 Professions Code): NO.PARKING ElSPACES PROVIDED L as owner of the Property. „111 du the „wn'I. :Intl the --- -- -------- -• --- --- structure is not Intended or ollited hII sale(Seeuon 711.1.1,�( PROPOSCO USE OF BUILDING 13usinesS and Prol'eSSians ('tide). - - Q LE —77 NDING ENDING AGI•NCY 1),, herchy al•firin that there is a conslluetion lending agency I"(n• the perlormance of the wort. Ilor "I ich this pernllt is Issued --- ---- --- (Sep'. 3097•Civ.('.). PROPOSED MAX.OCC. `—) Lender's Name X APPLICANT fpNPJ=� h ek _ 17 TZ NNei 6j4 ' 1 Q l/( Lender's Address ADDRC t certify that I have read IhiS application and stale that the '� 'L t " above information is correct. I agree to comply with all Count) PER I ordinances and State hews relating to building construction•and MIT FEE hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for ins ection purposes. _ TOTAL FEE SEF REVERSE FOR EXPLANATORY LANGUAGE SignaturfUr PerminC ne