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Home My Public Portal About5729 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 CE 875(11-84) M ISCELLANJUS APPLICATION I hereby affirT that I have a certificate of consent to self COUNTY OF LOS ANGELES r BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or i a certified copy thereof(Sec.3800,Lab.Q. I + Policy No. Company FOR APPLICANT TO FILL IN BUILDING pD DR ESS ❑ Certified copy is hereby furnished. ADDuILDRENSS IJ IG 9 5'7.2RQSEM ), 1' , EkD Bjjq( 14 WQLE C11/ CA 917LOCALITY 0 Certified copy is filed with the county building inspectionOCALITY NEARESTIF department. L cRoss sr. .67 Date Applicant NEAREST DISTRICT NO. GROUP TYPE CESSED BY CROSS ST. A CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL !/O ` COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL 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 SIZE OF LOT ,. EXISTIN LD G. I certify that in the performance of the work for which this v o permit is issued,I shall not employ any person in any manner OWNERWhOny so as to become subject to the Workers Compensation Laws. OCCUPANCY GROUP MAIL Date Applicant ADDRES $OO WEA �.,y�,�• '-r�� - (—TEL. LU NOTICE TO APPLICANT: If,after making this Certificate of CITY k— No. � OCCUPANT LOAD 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 or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. 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 REq'D O PROVIDED D SPACES License Number Lic. Class t✓�1�� TFDOU LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a PROM: TO: licensed architect or a registered professional engineer SIZE OF NO.OF 4INSPTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES E inessandProfessionsCode). FINAL APPROVAL v2`4 9 fPRESENT USE OP BUILDINGLic.or Reg.No. DateHOME OWNER BUILDER DECLARATION NO. OF EXISTING BUILDINGS Wk . ; � iLL, ''=j ON LOT AND USE U I hereby affirm that I am exempt from the Contractor's .4_'M License Law for the following reason (Section 7031.5, Busi- - ness and Professions Code): NO. PARKING ==LI r):li_• ❑ 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 o 7 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 grdinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon t above-m ti d p perty for inspectionpurposes SEE REVERSE IF EXPLANATORY LANGUAGE � it 27 9 �'. Si ature of er tte ate WORKERS'COMPENSATION DECLARATIONICE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self 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 ADDRESS.�A2t�yru�� Certified copy is hereby furnished. BUILDIADDRESSNG I/T4UP LOCALITY 0 Certified copy is filed with the county building inspection)( LOCALITY �/&yt','9_ �� NEAREST department. J� 6 CROSS ST. Date Applicant NEAREST y�,( /� DISTRICT NO. G OUP TYPE P CESSED BY CROSS ST. L� ut)J 1 V/6 ' I �/ - CONST.(� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a V COMPENSATION INSURANCE DESCRIPTION LOT NO. HLO CK 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 ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. �� d I certify that in the performance of the work for which this ; permit is issued,I shall not employ any person in any manner OWNER Cj?j4•M (erift ls-& � b ,� y SO as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUPMAIL Date Applicant ADDRESS Z N. VT5W�7 NVb . o C:)8 NOTICE TO APPLICANT: If after mak' �(�hal UYI( -41 this Certificate dk CITY TELo..r OCCUPANT LOAD °W Na 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 USEGEOLOGY INSPECTION ❑ deemed revoked. ❑ El No Spec. Knowl. 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 is in full force and effect. PARKING r �� SPACES REQ'D PROVID EO License Number Lic. Class - LIMITED TIME USE Contractor Date DATE DATE FROM: To: INSPECTOR'S I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF SIGNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). 1�__- U7�_ FINAL APPROVAL PRESENT USE OF BUILDING 1rJ"LwI Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT ANI I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness usiness and Professions Code): NO. PARKING I,!�I,1- ! s -• ! " SPACES PROVIDED - - " ElI, 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). CONSTRUCTION LENDING AGENCY )L PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency crly for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). Lender's Name PROPOSED MAX. OCG. Lender's Address PERMIT FEE 1� I certify that ave res application and state that the above informati n is correct.I)agree to comply with all County ISSUANCE FEE ordinan s an Stat laws fdlating to building construction, and her by a horiz one;esentatives of this County to enter TOTAL FEE upon th ab e-men . I property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Dat WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,nor a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING �Z N �� 13/ LOCALITY ADDRESS T / �+ //G, Certified copy is filed with the county building inspection LOCALITY /g r�G0, r /-4 / / -/C ✓ NEAREST department. CROSS ST. Date Applicant NEAREST DIST T NO. GROUP TYPE P CESSED BY CROSS ST. � Q : CONST.. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o �/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLL') STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOW o vB oT 5 IRV E SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. a 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. MAIL ® � OCCUPANCY GROUP o ADDRESS• U Date Applicant NOTICE TO APPLICANT: If,after making this Certificate of CITY rr. W' —TT,- �a� 3x33 OCCUPANT LOAD 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 or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. 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 is in full force and 9415;11163-seffect. PARKING REq'D PROVIDED /� • / SPACES License Number Lic. Class ��d K �,V� �D� LIMITED TIME USE Contractor Date `� P. DATE DATE ❑ 1 am exempt from the licensing requirements as I am a PROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 13REIP URE inessandProfessions Code). y �v �_ FINAL APPROVAL lPRESENT USE OF BUILDING/� 1 _'7Lic.or Re .No. DateI:z—/7u- J_lU 100 1 2/10/93 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 14 i 1 j C ON LOT AND USE w 8141 PN 4:.77 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 c/�l ❑ 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 sR�✓{` 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 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 above-mentioned property for inspection purposes. ` SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date i WORKERS'COMPENSATION DECLARATION ICE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that 1 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. r Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. XX'^ LDIE3NG9 / LOCALITY •.AO BUIDR _ Certified copy is filed with the county building inspection LGCALITY;� NEAREST department. 9 �., CR 099 ST. ,,yy�� Date Applicant NEAREST DISTRICT NGRI�UP TYPECONST LEGAL BY CR084 ST. !/ �0/�J lye CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL No. ICIRCLEI (This section need not be completed if the work involved TRACT Now ON LOT S. 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 f/ ci permit is issued, I shall not employ any person in any mannf+go, owvR of buildill Ro as to become subject to the Workers'Compensation Laws.r OCCUPANCY GROUP, SAIL. �a o ADDR SS r Date Applicant w NOTICE TO APPLICANT: If,after making this Certificate of CITY �� No OCCUPANT LOAD Exemption, you Should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you mast forth- ; ❑ with comply with such provisions or this permit shall be } TRAILER USE GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. 1 OCCUPANCY INSPECTION❑ Panic Devices LICENSED CONTRACTORS DECLARATION i _ 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 a,,� 4 effect. 1 �=-�•SiCle of business PARKING REq D 1 pROVID 6D SPACES 11-- License Number -- Lic. Class LIMITED TIME USE Contractor --Date DATE DATE FROM? . I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF 1 SIGNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date ROME OWNER-BI11LDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE 1 hereby affirm that I ant exempt from the Contractor's �I�'✓11` License Law for the following 'reason (Section 7031.5, Bust- / ness and Professions Code): NO. PARKING El1, 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). CONSTRUCI'ION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency I 7 for the performance of the work for which this permit is C) Issued(Sec.3097,Civ.C.). I Lender's Name C, PROPOSED MAX.OCC. Lender's Address _ PERMIT FEE certify that I have read this application and state that the µ ;1' 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 I TOTAL FEE 25.00 upon the above-mentioned property for inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE XX FWJ�I�C XX ,�! I WORKERS'COMPENSATION DECLARATION CE 876(11-84) M I SC E L LA N E� •U'o'A P P L I C A T I O N 1 Ivereby affirm that I have a certificate of consent to self insure, or a certificate of workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION LLLIII a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company ! FOR APPLICANT TO FILL IN BUILDING �/f ij 7 ADDRESS /O� / Certified copy is hereby furnished. -BODRE ss,G• S7 eIq Z�SEMir �lV�. LOCALITY r X� ADRE � Certified copy is fried with the county building inspection--7 LOCALITY G NEAREST department. 3M TEMP UP Gt i'y ft `D7gO CROSS ST. Date Applicant -��"HE-ARBST DISTRICT NO. GRO P TYPE CESSED BY CROSS ST. ��D y CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO.OF BLDGS. NO. ICIR C LE) (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. !a. p I certify that in the performance of the work for which this c"i permit is issued,I shall not employ any person in any mannerkX owNER of --.bulldin �. LEW £ h90Q 1E C-3so as to become subject to the Workers' Compensation Laws. ! MxIL p , OCCUPANCY GROUP ti I ADDRESS O S O� �� , ~ Date Applicant u L. NOTICE TO APPLICANT: If,after making this Certificate of i CITY NO. OCCUPANT LOAD �y 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 I TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked. I ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices 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 a "fix_ .Name of business }10 i-1 IVAi PARKING :=effect. --- -- ' SPACES REo'D PROVIDED 1 — 1 License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a PROMO TO: licensed architect or a registered professional engineer SIZE of NO.OF I SIPEATUR' acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL �-1 Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �J A ON LOT AND USEi 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING EJI, 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 4 I— for the performance of the work for which this permit 1S -; Ijk issued(Sec.3097,Civ.C.). �.� :,1 ': ! I Lender's Name PROPOSED MAX.OCC. •� _ Lender's Address I certify that 1 have read this application and state that the PERMIT FE25.00 E above information is correct.1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby a hor)ze representatives of this County to enter TOTAL FEE 25.00 U t re b e-mentioned property for inspection purposes. : I tX SEE REVERSE FOR EXPLANATORY LANGUAGE lt=d � - _ .. Signature of Pennitle Date I } � 1VORKERS'COMPENSATION DECLARATION 76M444 M I SC E L LA N E O U 8 APPLICATION i I hereby affirm that a certificate of consent tself CE 875 111-841 COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION I insure, or a certificate of Workers'of 1Vrkers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO PILL-IN BUILDING ADDRESS Certified copy is hereby furnished. g 'DRESS `i ( r), LOCALITY i 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. foe— Date Applicant NEAREST 'ISTRtCT NO. GR UP TYPE / P CESSED BY CROSS ST. ,' �i 3 CONS Tf/ CERTIFICATE OF EXEMPTION FROM tVORKERS' LEGAL Q dj' COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAI. HIGHWAY No, (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLOG (This section need not be completed if the work involved TRACT NOW ON LOT S. U3E ZONE SPECIAL CONDITIONS by the permit is for one Hundred dollars (S 100) or less.) USE OF I11, 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 S.Lew , 53 %G l e so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP 'DRESS 3?0o1 Ccgr1✓o. Sf. S e 3o n I Date Applicant _ NOTICE TO APPLICANT: If,after making this Certificate of TY rioL' OCCUPANT LOAD Exemption, you should become subject to the tVorkers' SQ �J C Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: I with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION[] No Spec. Knowl. a deemed revoked. ~ OCCUPANCY INSPECTION Panic Devices N LICENSED CONTRACTORS DECLARATION m I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Busi SAFETY PERMIT (41ST ITEMS BELOW NO.OF EXITS v ness and Professions Code,and my license is in full force and effect. SPACESG REq"b O PROVIDED License Number Lic. Class ll�� LIMITED TIME USE Contractor Date W GATE DATE I am exempt from the licensing requirements as I am a PROM! TO! d I licensed architect or a registered professional engineer s,zE of Np,OF INSPECTOR'S z acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG TORE , °m inessand Professions Code). tpy PRESENT USE OF BUILDING FINAL APPROVAL j G'dj � Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS G� ON LOT AND USE I hereby affirm that I am exempt from the Contractor's G�,I� } License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING MI, 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 A, 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.). I Lender's Nameco PROPOSED MAX.OCC. C:) Lender's Address I I certify that 1 have read this application and state that the PERMIT FEE 25.00 CJ�� above information is correct.I agree to comply with all County ISSUANCE FEE ,2'I ordinances and State law relating to building construction, r� and hereby author' a ntatives of this County to enter TOTAL FEE 25.00 ;} u on the a tipndd property for inspection purposes. �- SEE REVERSE FOR EXPLANATORY LANGUAGE cc I' a uP rmiDate ttee IIA 0 ._n "e