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Home My Public Portal About5727 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76 44 (2-80) uVli I SC E L LSA d`tl E®U S APPLICATION I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES 6UILDING AND SAFETY 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 a ADDRESS ❑ Certified copy is hereby furnished. AU" "57L� LOCALITY r_1 Certified copy is filed with the county building inspection ADDRESS NEAREST department. OCALITY n7Yfd�^I L Ct6e• �.A.- C� :1.Qn CROSS ST. Date Applicant NEAREST �j f""' VV 1 /I 7 o v DISTRICT NO. I GROUP TYPE ILa5RZESSED BY CROSS ST. LAS I VN#1n CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 0C COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL 0 (This section need not be completed if the work involved NO. OF BLDGS. P TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars (5100) or less.) USE OF SIZE OF LOT EXISTING BLDG. cc 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 WNER +� � O U so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP LLI Date Applicant ADDRESS .W0C� (�,C 1 L�jpy CL PP )T� NOTICIi TO APPLICANT: If, after making this Certificate ofCITY zee � o�Q/13 LC) }�OC{/o 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 or this permit shall be TRAILER USE GEOLOGY INSPECTION NOSpec. KnOWi. ❑ deemed revoked. P LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[] Panic Devices ❑ 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 ander �� . effect. PARKING SPACES REQ'D = PROVIDED O License Number Lic.Class MA-u, . o&& 6 t e-0-f p p i.U' Sc LIMITED TIME le Contractor Date DATE DATE ❑ -1^�-.Y�i I.r I am exempt from the licensing :eyuirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF -.-,M, INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES +�• SIG NA�RE. o iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL /2-Cz Lic.or Reg.No. Date ( •L 7 NO.OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION D 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 1V ❑ I, as owner of the property, will do the work and the � structure is not intended or offered for sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY ( OLWC, I hereby affirm that there is a construction lending agency I� 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 reud 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, TOTAL FEE and hereby a ize representatives of this County to enter u n the abo a-m nt' ed property for inspec Ion pur oses. SEE REVERSE' FOR EXPLANATORY LANGUAGE . ��-. Signature of Peomit a Date WORKERS'COM PLNSATION Ui:CLARATiON CE 875(11.84) M ISCELLANEOUS APPLICATION 1 hereby affirm that 1 have a certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or :I certified copy thereof(Sec.3800,Lab.Q. BUILDING Policy No. Company FOR APPLICANT TO FILL IN ADDRESS ,�/, S'-QL'irJZGs�-sem Certified co is hereby furnished. �` AIlILDING li copy y XX .ADDRESS S2 LOCALITY I ' Certified copy is filed with the county building inspectior; LOt ALITY /7 NEAREST department. XX _ 7� crtoss ST. Date _Applicant NEAREST DISTRICTNo. FUP TYPE / P oCESSED BY CROSS ST. �/ (aJyp �[J!� CONST. - � 1 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL C'OD4PENSATiON INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHwwr No. (cIR CLE) STATE MAJOR SECOND LOCAL NO. OF SLOGS. (Tills section need no( be completed if the Work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by (Ire permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. V (/- 1 certify that in the performance of the work for which this c permit is issued, I shall not employ any person in any manneki OWNER of buildin r su as to become subject to the Workers Compensation Laws. S OCCUPANCY GROUP ° MAIL / I- ADDRESS 1z:1r Date--_— Applicant — )) C_ NO'flCl: '1'O APPLICANT: If, after making this Certificate of clTr Frl� a�° =�'Ly No. OCCUPANT LOAD Q 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. OCCUPANCY INSPECTION ❑ Panic Devices a 1.IC .NSED CONTRACTORS DECLARATION 1 Ilerchy affirin 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 ani-X i errect. Name of business PARKIN SPACESr REQ'D PROVIDED License Number Lic. Class e s LIMITED TIME USE Contractor____— —____— Date DATE DATE FROM: TO: El 1 ani exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S �+ P g SIGN TORE acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING l l _lb Lic.or Reg.No.___ Date / WICil G=E= IiOhIE OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS O ON LOT AND USE I hereby affirm that I am exempt from the Contractor's [11I�J-[{I i[fi License law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 1 '1 F] 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 affirin 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__—___—_ .____—_— _— - �A PERMIT FEE 1 certify that I have read this application and state that the 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 representatives of this-C-ounty to enter TOTAL FEE 25.00 XX t'Tlrcahov Icd property for inspection purposes. r SEE REVERSE FOR EXPLANATORY LANGUAGE _ XX % i Cir•n.nu.•.•I 1'r•nni Ir.• tl;llt•