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Home My Public Portal About5739 ROSEMEAD BLVD_Miscellaneous__ 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, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING /Ja� �Lee'GL /JA ADDRESS /✓ �- Certified copy is hereby furnished. ADORessg�]�� f-07-fYa j L' LOCALITY DCertified copy is filed with the county building inspection OCALITY NEARE department. Tl ► G n�,�, "I 4-1 f, N9 SSTT. Date Applicant NEAREST A �_r. -y—T y �+ DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. 1�1�.� \ \l��I , p' -^ CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a r COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK 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 I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. CD a permit is issued,I shall not employ any person in any manner OWNER (�{I QJ �' so as to become subject to the Workers' Compensation LawsOCCUPANCY GROUP DDRESS Applicant MAIL $�� E3 Date uo AI NOTICE TO APPLICANT: If,after making this Certificate of CITY (_ . - No aL� 6,33��5 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 or this permit shall be 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 is in full force and effect. Ge9, PARKING SPACES REO,D � PROVIDED , License Number Lic. Class ` LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF � J(Q} NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. I ZDSTORIES i SIGNATURE iness and Professions Code). FINAL APPROVAL 'r,"SENT USE OF BUILDING _l JJ Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 'et Q IA�� FE ON LOT AND USE �/ Il/ I hereby affirm that I am exempt from the Contractor's r��l 0�'I�U—��illi 311��? License Law for the following reason (Section 7031.5, Busi- I �"11'' ness and Professions Code): NO. PARKING r—r r ElI, as owner of the property, will do the work and the SPACES PROVIDED v�-l� 1 � 'xo.17 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY P OPOSED 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 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 representatives of this County to enter TOTAL FEE wove-menpr fonspection purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ture of Permittee Date I WORKERS'C041PENSATION DECLARATION CE 875.1 7-84) M I SC E L LA N EO U� APPLICATION CE 7.ri I'l�--reby affirm that I have a certificate o£ consent to self 'BUILDING AND SAFETY DIVISION COUNTY OF LOS ANGELES insure, or a certificate of Workers'Compensation Insurance,or Li. D' a certified copy thereof(Sec.3800,Lab.C.). — , Policy No. Company i FOR APPLICANT TO FILL IN ADDRESS p�/ Certified copy is hereby furnished. a1L01NIS ADDR E55 LOCALITY Certified copy is filed with the county building inspection ;LOCALITY NSARCROSS sr. department. Date Applicant (NEAREST .DISTRICT NO. GROUP TYPE P�R��JESSED BY 1 GROSS ST. it CONS T�� + CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V I COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) 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 (SI00) or less.) I USE OF ! f SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. ppI MAIL r OCCUPANCY GROUP OI ADDRE33 _ ! Date Applicant — TEL. OCCUPANT LOAD - NOTICE TO APPLICANT: If, after making this Certificate of clrY No. - Exemption, you should become subject to the 1Varkers' , APPLICATION FOR ' EXIT HARDWARE: ZZ 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 I hereby affirm that I am licensed under provisions of Chapter I SAFETY PERMIT ❑ (LIST ITEMS BELOW) I 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 f /' r effect. PyRKIACES S REWD PROVIDED 5. N o0 , License Number Lic. Class LIMITED TIME USE H Contractor Date DATA DATE ZF.IOM: TO: H I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S d m t g p g SIGNATURE 2 acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES o inessandProfessionsCode). FINAL APPROVAL D �0 f � O PRESENT USE OF BUILDING `i Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS i"► �� ON LOT ANIl�_ I hereby affirm that I am exempt from the Contractor's I DSI r�-I;+ �(� 1 `T-A 1' 1 I 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 1 7044,Business and Professions Code). X.J!r .PROPOSED USE OF BUILDING i 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.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address ! I certify that I have read this application and state that the PERMIT FEE y 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 County io enter TOTAL FEE 25.00 ' upon th v mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date