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Home My Public Portal About5707 ROSEMEAD BLVD_Miscellaneous__ I WORKERS'COMPENSATION DECLARATION 176M444 ICE 875(11-84) M ISCELLANEOUS, APPLICATION I ] affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES 13UILDING AND SAFETY DIVISION insureure,, o or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). (Adtl(,`0 1 Policy No. Company. / FOR APPLICANT TO FILL IN 8I7 ILDING Coe v' IN r Certified copy is hereby furnished. fiq-C�6-.f71 Xx 5-1 icaql-�M-0jLV f, LOCALITY M � C4� Certified copy is filed with the county building inspection LOCALITY / I7 NEAREST LOCALITY Xy. C' l�(� C�'} X71 /ff� CROSS ST. C& 4 Date Applicant NEARESTft I 1^ C f 1 DISTRICT NO. GROUP ITYPE PROCESSED BY CROSS ST. YO L� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLET STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT UPCIAL COND E ZONE SPEITIONS by the permit is for one hundred dollars (5100) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this C permit is issued, I shall not employ any person in any manne3CX', OWNER of building so as to become subject to the Workers' Compensation Laws. MAIL ) Vn� //�q 'I(�� -��/ ��/// OCCUPANCY GROUP C ADDRESS / CaN Yc I(i�8/I /'1,J� r Date Applicant n7 L NOTICE TO APPLICANT: If, after making this Certificate of CITY �4ff(11�a� C� NOL � OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth PPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be I TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. , LICENSED CONTRACTORS DECLARATIONi Panic Devices OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter I 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 arlX effect. Name of business PARKING ' PROVIDED 1 I License Namber_. _Lic. Class J" &'WY � r+ r ' E SI-ACES REq'D � - LIMITED TIME USE Contractor Date DATE DATE El1 am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S EXISTING BLDG. STORIES i IGNATURE acting in my professional capacity (Section 7051, Bus- �' �� I I•,.;�:i' - '• inessgndProfessionsCode). /�/ / FINAL APPROVAL ��/ 1 •1 PRESENT USE OF BUILDING P%-- ` t- I� Lic.or Re No. Date 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 F1I, 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 �1 1 Hereby affirm that there is a construction lending agency G � for the performance of the work for which this permit is t1f 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 ordinanc¢¢s and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25- 00 upn ie above-Inentio roperty for inspection ur oses I (f n(( ISEE REVERSE FOR EXPLANATORY LANGUAGE XX Signature of Permittee Date 1 WORKERS'COl11PENSATION DECLARATION 6M"4 5 878(11.84) M ISCELLAN EQU 7 APPLICATION.. I hereby affirm that I have a certificate of consent to self --- i insure, or a certilicateof Workers'Compensation Insurance,or I COUNTY OF LOS ANGELES U ''DI ' 17SFETY D_t�IS a certified copy thereof(Sec.31300,Lab.C.). Pnlicy No./2 / 7any Com p FOR APPLICANT TO FILL IN JNDDRESS 1 entified copy'is hereby furnished. eu)LD,�I�NG R:£SS O 1 CA LlTY `moi '" > i Certified copy is filed with the county building m department. SpeCiIon .*- Y CRST .' CROSS sr. I)n tC Applicant. NEAREST / a,Jl �] n DISTRICT NO. GROUP TYPE ��• P CESSEO HY CROSS ST. (r7�+ G�YCIi7•J CONST t'1:R'ftl'IC.aTE OF EXE�iPTtO: FR OR1;.ERS' LEGAL COI+iPEASATION 1NSi RANEE UKSCRIPTfON LOT NO. BLOCK I+wP Nle hw wv ,Io. (cI++CLt1 STATE MAJOR SECOND LOCAL NO. OF Boa GS. (TIT!$ section need not be completed if the work involved TRACT NOW ON LOT USE jONEl SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) use or i SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this i _ Permit is issued. I shall-.lot empioy any person in any mann sI, as lit berome snhiert :u the Wntkers' Compensation Laws. MAIL l OCCUPANCY GnOUP i! ( ADOR ESS � ' ' �[ Date-_ _Applicant •pp, NOTICE TO APPLICANT: If. after making this Certificate of � CITY Nc�p/tf`2y2-03,:� { OCCUPANT LOAD t ! Exemption. you should become subject to the Workers' Compensation provisions of the Labor Code.you must forth- I APPLICATION FOR ? EXIT HARDWARE: with comply with such provisions or this permit shag be i TRAILER USE E+, GEOLOGY INSPECT)DN fel No Spec. Knowl. LI deemed evoked. � !1C'i VSf:!)t{)Ni'R:1( I'f)R$ DECLARATION tNSPECTICN Panic Devices I hereby affirm that I am licensed under provisions of Chapter 9 icommencin8 with Section 7000) of Division 3 of the Bus* t 9ArETY PERMIT I] (LIST ITEMS BELOW) 1 NO. OF EXITS ness :rid Profession-Cade. and my license is in full force a flSS fPPACES REO O U ,^--� SPACE9 PROVIDED I i l i,::•n%v Number __. _ ._ _ t.i . ('lass _ LIMITED TIME USE l^— I owre owrg CI ant exempt from the licensing requirements as I am a I icensed architect or a registered professional engineer SIZE OF NO. OF l INSPECTOR'S t( actinic in my professional capacity iSection 7051. Bus- EXISTING BLDG. .S' zoo STORIES f j SIGNATURE- Mess IGNATUREmess and i'ru('essions Code). r ` __„ PRESENT USE OF BUILDING � FINAL APPROVAL LiC.or RCC. No. _---- Date L/� HOME OWN1711-III'ILDER DECLARATION NO. OF EXISTING BUILDINGS I b 1{ ly ?C"s,;;_.E;,;;'. ON LOT AND USE I hereby affirm that I alit exempt from the Contractor's �!!' License Law for the following reason (Section 7031.5, Bus]- j ness and Professions Codet: No. PARKING SPACES PROVIDED 1, as owner of the property. win do the work and the 3033 structure is not intended or offered for sale (Section 1 7044.Business and Professions Code). ' CONSTRucri ON LENDING AGENCY PROPOSED USE or 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.C.). 4 Lender's NarnR. __. PROPOSED MAX. OCC. - Lender's Address ...._.._. .__ _ 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 F££ ordinances and State laws relating to building construction, �. and hereby authorize representatives of this County to enter TOTAL FEE .15-00 j tZoti-thp-a sue-mentioned to ertr for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature: