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Home My Public Portal About5644 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION a CE B75(11-ea) MISCELLANEOUS APPLICATION CE 87 I ] affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insureure,, o or a ceetificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.Q. Policyf4o. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING C (0 V l (40- O �� LOCALITY ADDRESS J DCertified copy is filed with the county building inspection LOCALITY NEAREST department. 2�N �Q, cRoss ST. Date Applicant NEAREST �� / - w S DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. EL A CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP 1116HW Av STATE MAJOR SECOND LOCAL OF BLD 63. NO. (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS NO. by the permit is for one hundred dollars ($100) or less.) USE of I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. 0 permit is issued,I shall not employ any person in any manner OWNER LDNG &MA y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADDRESS 3 4 64LMA / .� V Date Applicant p NOTICE TO APPLICANT: If, after making this Certificate of CITY A W, ,blz"e ) TEL OCCUPANT LOAD z Exemption, you should become subject to the Workers' I., APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- with comply with such provisions oI this permit shall be TRAILER USE [] GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PER ❑ (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. I)MCPARKING /';�_// / 'D � PROVIDED License Number Lic. Class I." SAIV C�'I hn-1 AQ/� /"�e ' SPACES REQ'r �a�r� LIMITED TIME USE Contractor Date `t 14 d . DATE DATE El ' I am exempt from the licensing requirements as I am a 0-J FROM. TOI 1CTOR'S licensed architect or a registered professional engineer SIZE OF NO.OF sIG TORE JN acting in my professional capacity (Section 7051, Bus' EXISTING BLDG. STORIES iness and Professions Code). PRESENT OSE OF BUILDING QIJ FINAL APPROVAL I Lic.or Reg.No. Date mlt Ito HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS ON LOT AND USE 1 F— �- 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 SPACES PROVIDED ul tl '+ 3/fc-/9n_ ElI, as owner of the property, will do the work and the ��4? �f�ot structure is not intended or offered for sale (Section 1 A a I 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDIN �t pA I(+� ' I hereby affirm that there is a construction lending agency � ) 0.4 I(� 2 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 +0 PERMIT FEE I certify that I have read this application and state that the above information is correct.1 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 u on the abov -mentioned prD%eyfor' pection purposes. a_g�%SEE REVERSE FOR EXPLANATORY LANGUAGE signature of Permittee Date WORqRS'COMPENSATION DECLARATION '!- CE 875(11-84) M i SC E L LAN E®U S APPLICATION I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insgre, or a certificate of Workers'Compensation Insurance,e,or • a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR.APPLICANTTO FILL IN BUILDING AD Certified copy is hereby furnished' ADDRESS 5644 N. ROSEMEAD BLVD.' LOCALITY F department.c.py is filed with the county building inspection OCALITY TEMPLE CITY, .CA. 91780 NEAREST CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PR CESSED BY CROSS ST. LAS TUNAS D CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �O COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF BLDGS. (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 /,//// SIZE OF LOT EXISTING BLDG. L '3 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 OWNER so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP Cd Date A hcant MAIL 8939 PALMA VI A, . ADDRESS E; r~j PP L. NOTICE TO APPLICANT: If,after making this Certificate of CITY SAN GABRIEL NO.' N/A 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 USEGEOLOGINS ❑ E] Y INSPECTION El Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E] Panic Devices El 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 J License Number Lic. Class MID SAN ABRIEL VALLEY MEDICAL CLINIC 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 SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date EDICAL FACILITIES HOME OWNER-BUILDER DECLARATIONNO. OF EXISTING BUILDINGS ! G ON LOT AND USEi+'I fo , I hereby affirm that I am exempt from the Contractor's (V�7-J +.. Lam/7,. License Law for the following reason (Section 7031.5, Busi- J, 1 PM 32-25 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 PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency ICAL FACILITIES 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 P��-'d 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 tate laws relating to building construction, and hereby h ize re sentatives of this County to enter TOTAL.FEE asfi,s upon the ve- ed ropert for inspctio ose^./ � SEE REVERSE FOR EXPLANATORY LANGUAGE ' Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereb3/'afcert that I have a certificate of consent tself COUNTY OF LOS ANGELES- .. BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS—, k ADDRESS ,ZytJ1 Certified copy is hereby furnished. BUILDING ADDRESS b �� LOCALITY VC✓l 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST /�c �q�r DISTRICT NO. GROUP TYPE P CE SSED BY CROSS ST. OS Ue)a-S /�� CONST. .�f ' CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ,67 COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOW ON LOT NO. ICIRCL6)LOT S. USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) IU OF SIZE OF LOT EXISTING BLDG. d 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 OWNER (j•-r huLi lot;O s17 so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o Date Applicant ADDRESS 3 �!as W San TEL, L. OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of clTr ��15 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 oI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ ❑ ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 9 (commencing with Section 7000) of Division 3 of the Busi ❑ (LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code,and my license is in full force and 1/1 effect. a Me & • 'INC s ' PARKING REQ'D PROVIDED SPACES License Number Lic. Class061DOMC LIMITED TIME USE Contractor Date DATE DA!! wORs TE PROM: TO: 0-4Iwc ' I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF sl N URE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL .lJ�/ •i �•')-• - Lic.or Reg.No. Date !i HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT ANO USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, BusiLIM - 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 PROPOSED USE OF BUILDING 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 the abo e-mentiorted property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si ature of Permitte Date WORKERS'COMPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION c, :p a CE 875 (2-80) I h4j,, affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insu•'.' or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. ADDRESCompany i FOR APPLICANT TO FILL IN BUILDING S ❑ Certified copy is hereby furnished. (7 i��v� ❑ DDRESuILDINSG' ic. �1i /'S LOCALITY C Certified copy is filed with the county building inspection ANEAREST LOCALITY `�—� PC.0 C L CROSS ST. department. Date Applicant NEAREST DISTRICT NO. UP TYPE PROCESSED BY CROSS ST. r•,`v V �1 CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL CJQ 6- COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP p�dC`l - ,.,G,,,NAY >_NOOF NO. j (CIRCLE) STATE MAJOR SE.CONDIO.CAL CL BLDGS. (This section need not be completed if the work involved TRACT NO.W ON LOT USE ZONESPECIAL CONDITIONS V by the permit is for one hundred dollars (S100) or less.) USE OF 2 SIZE OF LOT EXISTING BLDG. C ,3 cc 1 certify that in the performance of the work for which this O permit is issued, i shall not employ any person in any manner' WNER t` Minr U so as to become subject to the Workers' Compensation Laws. ( t OCCUPANCY GROUP MAIL LU Date Applicant ADDRESS <) s�P �,I(;'L„ � ,"r,� IL N NOTICE TO APPLICANT: If, after making this Certificate of clTr�(� S J o� OCCUPANT LOAD Exemption, you should become subject to the WorkersLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forthen - with comply With such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION NO Spec. Knowl. ❑ deemed revoked. Panic D2VICeS ❑ 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 Pw:RKING. effect. SPACES ' Rr=Wo E= PROVIDED D 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 slzE of NO. OF I INSPECTOR'S acting in my, professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGN/ATURE iness and Professions Code). PRESENT USE OF BUILDING F t! 2 f90 1=, FINAL APPROVAL 2, r '� /•-' C ` Lic.or Reg.No. Date OFFTC— 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 SPACES PROVIDED ❑ 1, as owner of the property, will do the work and the 3 S 3 (1 structure is not intended or offered for sale (Section 7044, Business and Professions Code). /� ROPOSED USE OF BUILDING ///� / 1 O O o 0 1 r CONSTRUCTION LENDING AGENCY l/ l I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 1 = t issued(Sec. 3097,Civ.C.). C. Lender's Name PROPOSED MAX. OCG. 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, ; and hereby authorize represe atives of this County to enter TOTAL FEE k on the ove-men 'oned p erty for inspection urpo es. SEE REVERSE -OR EXPLANATORY LANGUAGE �3 Signature of Permittee D e