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Home My Public Portal About5676 ROSEMEAD BLVD_Miscellaneous__ i WORKERS'COMPENSATION DECLARATION I 76M444 MISCELLANEOUS APPLICATION t� I Hereby affirm that I have certificate of consent to selfCE 875 (2-80) , COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' rs'Compensation Insurance,or I a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILRESSDING % ADDLO Certified copy is hereby furnished. I BUILDINGO` LOCALITY ADDRESS Certified copy is filed with the county building inspection I �j NEAREST department. LOCALITY T� e �C4� %K� / CROSS ST. Date Applicant RAREST w�O�J_ / U /� DISTRI O. G CONST PRO SSED BY CROSS ST. �J'W ^ r CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NI(.HWAr �. NO. F BLDGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS 0 by the permit is for one hundred dollars ($100) or less.) UXSE OF 0 SIZE OF LOT EISTING BLDG. , I certify that in the performance of the work for which this I permit is issued, I shall not employ any person in any manner NER AA /io C) so as to become subject to the Workers'Compensation Laws.I -�`� OCCUPANCY GROUP / W ADDRESS GI�?C%r OL �'�•'�L� �� ,►/? CL Date Applicant c4 NOTICE TO APPLICANT: If, after making this Certificate of c! I TY2Q (rem Now .249— OCCUPANT LOAD Exemption, you should become subject to the Workers" PLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth-i with comply With such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION deemed revoked. NOSpec. ICtlOwl. ❑ � I 1:1 Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT I--I (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. ffect. , SPACES REO'D == PROVIDED license Number Lic.Class - +,� LIMITED TIME USE ,,h.ontractor Date DATE DATE ❑ ' FROM: TO: I am exempt from the licensing requirements as 1 am a licensed architect'or a registered professional engineer SIZE OF NO. OF INSPECTOR'5 acting In my professional capacity (Section 7051, $US-i EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). EFINAL APPROVAL >`; ESNT USE OF BUILDING �'• ( I +v Lic.or Reg.No. Date e + 1 �' `� �• I j NO.OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION 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- o 4 1 Q 1 A ness and Professions Code): NO. PARKING SPACES PROVIDED a 0 0 0 88 ❑ I, as owner of the property, will do the Work and the structure is not intended or offered for sale (Section I a u o a a a O In 7044, Business and Professions Code). ++ P POSED USE OF BUILDING 08.01 -83 CONSTRUCTION LENDING AGENCY I 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.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the I above information is correct.I agree to comply with all County I ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter upon the above-mentioned property or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE igna of Permittee Date _ I 1 .RJ l•VIYIIlil�u/'111v,� ✓L:I Mnt%11VIN I 20-0063DPW12/00 lrli I~L�r1�tilGIVV 7 tkr l- t�.Z�.r1I Ivlti n that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,of a certificate of Workers'Compensation Insurance,or a_artified aopy thereof(Sec. 3800, Lab.C-) Policy No. Company FOR APPLICANT TO FILL IN PAD BUILDING ADDRESS ss 1p 4 ❑ Certified copy is hereby furnished. ' r ? kD-<C-117 �,LI/,D• TY ❑ Certified copy is filed with the county building inspection CITY zIP ' IT department. C p�� G�� i C4 • ��7gd ST. Date Applicant I SIZE OF LOT NO.OF BLDGS.NOW ON LOT :T Np GROUP TYPE CESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS' I uCONST.COMPENSATION INSURANCE TRACT BLOCK LAT NO. HIGHWAY (CIRCLE) STATE MAJOR SECOND LOCAL (Thissection need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL NE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) �rQ I certify that in the performance of the work for which this °property �lL $ 7SJ permit is issued, I shall not employ any person in any manner so as tq become subject to the Workers' Compensation Laws.: ADDRESS Ito OCCUPANCY GROUP Date ApplicantCITY l� n/i✓ ZIP �� NOTICE TO APPLICANT: If, after making this Certificate lk ' OCCUPANT LOAD 'of'Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices ❑ I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) NO. EXITS 9(commencing with Section 7000)of Division 3 of the Business El and Professions Code,and my license is in full force and effect. I PARKIN o License Number Lic.Class SPACES( ' REQ'D E= PROVIDED Contractor Date LIMITED TIME USE DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S and Professions Code). EXISTING BLDG. STORIES SIG)W Lit or Reg Na Date PRESENT USE OF BUILDING /L5-4 � FINALAPPROVAL HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License (I, Law for the following reason (Section 7031.5, Business and -Profession Code): NO.PARKING I, as owner of the property, will do the work and the SPACES PROVIDED p structure is not intended or offered for sale(Section 7044)1 PROPOSED USE OF BUILDING J �] Business and Professions Code). 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 (Sec. 3097,CIV.Q. PROPOSED MAX.OCG Lender's Name kPPLl ANT(PNMT) TEL Nq Lender's Address �D Ess (�2G 1��3/y7o I certify that I have read this application and state that the SAO RCiiC-14 C7, SICAeRI! /Y"40 f—C!C- ' 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 f ction purposes. I YOTAL FEE X SEE REVERSE FOR EXPLANATORY LANGUAGE o Permittee z Date