HomeMy Public PortalAbout5675 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
' CE 875(17-84) MISCELLANEOUS ®PPeIlATION
I hereby affirm that I have a certificate of consent to self I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
FICertified copy is hereby furnished. X HUIADDRESS N.LDING5675 Rosemead Ave. LOCALITY `
Itld p
FCertified copy is filed with the county building inspection LOCALITY Temple C�City, CVA 91700 NEAREST
department. l CROSS ST.
Date Applicant NEAREST DIS CT NO,
GROUP CONST.
)�
PE OC SSED BY
CROSS ST. ��
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (!
COMPENSATION INSURANCE DESCRIPTION I,OT NO. BLOCK MAP/ "•16� a�6-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 ZONE SPECIAL CONDITIONS
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.
a
permit is issued,I shall not employ any person in any manner x OWNER American Personnel Services Inc
so as to become subject to the Workers' Compensation Laws. MAIL
Date Applicant OCCUPANCY GROUP o
ADDRESS 9382 TElstar Avenue
w
NOTICE TO APPLICANT: If, after making this Certificate of CITY El Monte, CA NO. 818-571-7516 OCCUPANT LOAD N
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions oI this permit shall be I 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 Win full force and X
effect. PARKING REq'D PROVIDED
SPACES
License Number Lic. Class Chevron LIMITED TIME USE
Contractor Date Gas Station Foo I DATE DATE
0 I am exempt from the licensing requirements as I am a
PROM: To:
Bus-
licensed architect or a registered profbssional engineer SIZE OF
ENO.OF
INSPECTOR'S
acting in my professional capacity (Section 7051, BliS- XISTING BLDG. STORIES I SIGNATURE
mess and Professions Code).
Lic.or Reg:No. Date
X PRESENT USE OF BUILDING F'I`NAL APPROVAL
Exxon Gas Station/Food MartIV
HOME OWNER-BUILDER DECLARATION 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, Busi- V i 1� J �;;i'._:'?:;": �:: : r.�:•:
ness and Professions Code): NO. PARKING
❑ I, as owner-of the property, will do the work and the I SPACES PROVIDED
structure is not intended or offered for sale (Section t r 1
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING
I •hereby affirm that there is a construction lending agency Chevron Gas Station/Food Mart
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 thePERMIT 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 r
upon above-mentioned property f spect'on purpo e .
��—r SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
I I
WORKERS'COMPENSATION DECLARATION CE 854
7 (11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tsell' 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.C.).
e �I1A� BUILDING L
Policy�i.6tr," mpany !Q4 FOR APPLICANT TO FILL IN ADDRESS �/� 7x-1er—oc-_
Certified copy is hereby furnished. BUILDING (/�`/.� r h�
ADDRESS Sv A \ R y LOCALITY ✓� CGS
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST T� )A�AS rn s DISTRICT NO. G OUP TYPE P CESSED BY
CROSS ST. LAS l(/�W/ ;! �j ICONST.
O
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF BLD GS.
(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.
I certify that in the performance of the work for which this0
/�
permit is issued, I shall not employ any person in any manner 1( OWNER �E'�r C € �.c� 19
so as to become subject to the Workers' Compensation Laws./` MAIL OCCUPANCY GROUP a
ADDRES
Date Applicant 3C� �a GHQ I"
NOTICE TO APPLICANT: If,after making this Certificate of CITY/, T-EL /e' cv/"fi g OCCUPANT LOAD
Exemption, you should become subject to the Workers'
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 ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 0
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 SPACES
J�� 6r >�L_ / PARKING •;
effect. =v+ RE°'°
C d
License Number Lic. Class AI LIMITED TIME USE I
Contractor Date DATE
FROM: TO: y'1� 7 .l 'I' �
I am exempt from the licensing requirements as I am a -- - �(_L
licensed architect or a registered professional engineer SIZE OF NO. OF J INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES r SIGN RE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS f
ON LOT AND USE /• O'
I hereby affirm that I am exempt from the Contractor's V/ -
License Law for the followingreason (Section 7031.5, 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
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 ge- ioned p,rownyfor inspection purposes.
EE REVERSE FOR EXPLANATORY LANGUAGE
Sign u e o Permit ee ate '
RKERS'COMPENSATION DECLARATION pko
CE 87x5(71-84) MISCELLANEOUS APPLIC1TIoN
'I hereby affirm 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.
PolicyNo.—Company BUILDING
II FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished. AcoREss `, CJ �/�Q�� LOCALITY
Certified copy is filed with the county building inspection LOCALITY — NEAREST
department. CROSS ST.
Date Applicant NEAREST �� DISTRICT O. ROUP TYP PROCESSED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION 40T NO. BLOCK MAAVAY
NoPjsa�26r(cGiRCLe) STATE MAJOR SECOND LOCAL
NO. OF SLOGS.
(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. •'-� �"
I certify that in the performance of the work for which this CL
0
permit is issued,I shall not employ any person in any manner OWNER . C117so as to become subject to the Workers' Compensation Laws. �� /
AIL - OCCUPANCY GROUP o
�
Date A Applicant DRESS It3
NOTICE TO APPLICANT: If,after making this Certificate of 90 CITY NO. OCCUPANT LOAD z
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.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 SPACES REQ'D D PROVIDED
License Number Lic. Class LIMITED TIME USE
Contractor Date O ATL' OATH
FROM! TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer size of NO. OF I S1 NATURE
acting in my professional capacity (Section 7051, Bus- Ex TING BLDG. STORIES
iness and Professions Code). , FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date L-3 & d�A
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
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�' '
I hereby affirm that there is a construction lending agency f U 7 �-7/ °o $ z
for the performance of the work for which this permit is q�g
issued(Sec.3097,Civ.Q.
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,
and hereby authorize re re entatives of this County to enter TOTAL FEE
uppn the ove-m io rope�rty for insp tion purposes.
f// �� ��SEE REVERSE FOR EXPLANATORY LANGUAGE
na ure of Permi a Date
j J WORKERS'COMPENSATION DECLARATION CE 875
(11-84) M I SC E L LA^ O U S APPLICATION ,
hereby'affirm that I have a certificate of consent tself
f COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �
insure, or a certificate of Workers'Compensation Insurance,
S e,or •.
a certified copy thereof(Seo.3800,Lab.Q. - �'
LJ Policy No. Company BUILDING
FOR APPLICANT TO FILL IN ADDRESS 5475
Certified copy is Hereby furnished. I BUILDESSING S OS�BInj/sL�r LOCALITY
( ADDR
department.Certified Py is filed with the county building inspection LOCALITY Temple City CROSS ST. Lnf —Fw4m
Date Applicant NEAREST !�S=,7p TYPE CESSED BY
CROSS ST. Gaf���'r • C NSTCERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK InAP HIGHWAY STATE MAJOR SECOND LOCAL
% NO. OF BLDGS. 110. (CIRCLE)
(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 Itl
• I I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
permit is issued,I shall not employ any person in any manner OWNER f�/�( 03ILt s Co
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP
Date Applicant It ADDRL.ESS/300 So /zL q i
NOTICE TO APPLICANT: If,after making this Certificate of CITY pQ)(A NO-7 Z- /� 7-?00 OCCUPANT LOAD
TH
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be ❑
TRAILER USE ❑ E
GOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. p
ILICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
�j 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. PARKINSPACES REQ �J PROVIDED
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
1 am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer SIZE OF NO. OF FROM. To. INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG TORE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING 1
Lic.or Reg.No. Date
I `1
HOME OWNER-BUILDER DECLARATION NO. OF EXIUSESTING BUILDINGS
ON LOT AND )
1 hereby affirm that I am exempt from the Contractor's _ I
,J License Law for the following reason (Section 7031.5, 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
7044,Business and Professions Code).
Ig PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency t SGIVI."At-3t6 Om—b— /L
for the performance of the work for which this permit is I- I
issued(Sec.3097,Civ.Q. L
Lender's Name ,
Lender's Address
PROPOSED MAX. OCC.
I certify that I have read this application and state that the 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.,
and hereby authorize repre ntatives of this County to enter TOTAL FEE 25.00 ^ P.7
I I upon the above- ntioned roperty for inspection purposes.
/Z'7^ SEE REVERSE FOR EXPLANATORY LANGUAGE -
> n .J
Signature of P nnittee Date �^ CO
..I • i1