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Home My Public Portal About5743 ROSEMEAD BLVD_Miscellaneous__ i WORKERS'COMPENSATION DECLARATION CE 875(11-a4) MISCELLANEOUS APPLICATION I laffirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insureure,, o or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec. 3800,Lab.Q. Policy No.,—Company ` BUILDING . FOR APPLICANT TO FI CL 1N ADDRESS Certified co is hereby furnished. BUILDING -� �, py y ADDRESS� 'f1 Uy ., , LOCALITY DCertified copy is filed with the county building inspection LOCALITY / 1i NEAREST department. / J CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P OCESSED BY CROSS ST. Y r �"Jf i q CONST CERTIFICATE OF EXEMPTION FROM.WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP I 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 ZONESPECIAL 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 C:) permit is issued,I shall not employ any person in any manner OWNER I [� s' so as to become subject to the Workers' Compensation Laws. MAIL /t�! j n 4M OCCUPANCY GROUP o ®O W• J V V Date ADDRESS Applicant Lu NOTICE TO APPLICANT: If after mak' this Certificate of CITY i ITvo� OCCUPANT LOAD y Exemption, you should become subject to the Workers' APPLICA ION 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. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 51Panic 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 LY1 � , effect. \ 1! gs PARKING REq'D PROVIDED 1 I SPACES JJ ll�� License Number Lic. Class ` -� LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineerSIZE OF NO. OF INSPSIGEATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). PRESENT USE OF BUILDING �/ FINAL APPROVAL j,„L /� Lic.or Reg.No. Date // "/ _ ,3 — HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS !h ON LOT AND USE I hereby affirm that I am exempt from the Contractor's �'� C i'j;',_:_;f`': License Law for the following reason (Section 7031.5, Busi- ! , ness and Professions Code): NO. PARKING _ ,S? 1 ilu all ll,, 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 Lender's Address PROPOSED MAX. OCC. ' I certify that I have read this application and state that the PERMIT FEE � OO above information is correct.1 agree to comply with all County ISSUANCE FEE ordinances and St a laws relating to building construction, and hereby auth a representatives of this County to enter TOTAL FEE GZ/ upon the abov ne tioned Property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date I WORKERS'COMPENSATION DECLARATION 76M444 pp�� p p {gyp I APPLICATION/'► //�� ;CE875 (2-80) MISCELLANEOUS AI-PL.ICATI®N 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 'fl a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANTTO FILL IN BUILDING �� PDD RESS ❑ Certified copy is hereby furnished. BUILDING go� LOCALITY ❑ ADDRESS Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. Date Applicant EAREST DISTRICT NO. GROUP TYPE CESSED BY CROSS ST. i ' +�J CONST. C CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL UQ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. OF SLOGS. No. (CIRCLE) IL (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars (5100) or less.) USEOF SIZE OF LOT EXISTING BLDG. 0C I certify that in the performance of the work for which this I O permit is issued, I shall not employ any person in any manner OWNER �p I U so as to become subject to the Workers'Compensation Laws. MAIL ,�Q I OCCUPANCY GROUP I.I.I ADDRESS11. Date Applicant4a'l ad N NOTICE TO APPLICANT: If, after making this Certificate of LI !O No. OCCUPANT LOAD Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- AP LICATION FOR j EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION deemed revoked. i ❑ ❑ NO Spec. Knowl. INSPECTION Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSP � El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- r I NO. OF EXITS ness and Professions Code, and my license is in full force and I AJt�e effect. PA . REO'D O PROVIDED D /I PA.1 KING License Number Lic.Class LIMITED TIME USE Contractor Date I DATE DATE ❑ I am exempt from.the licensing requirements as I am a: i FROM: TO: licensed architect or a registered professional engineer SIZE OF 114 0. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). USE OF BUILDING FINAL APPROVAL PRESENT Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE � Q I hereby affirm that- I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and PCOfeSSIODS Code): NO. PARKING G Z.SPACES PROVIDED � L, j ❑ I, as owner of the property, will do the work and the I structure is not intended or offered for sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING 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. i Lender's Address PERMIT FEE I certify that 1 have read this application and state that the ISSUANCE FEE above information is correct.I agree to comply with all County i ordinances and State laws relating to building construction, TOTwL FEE and hereby authorize representatives of this County to enter 1 upon th G-W lone - roperty for insp ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE '5i at iIree Date I "'°'tKtRS `U`1`'LN'A1,UhllL`.L:"`A"U`` CE (11 MISCELLANEOUS APPLICATION Thereby affirm tivt. I Have a certificate of consent to self COUNTY OF LOS ANGELES I3UILIiING .ANI) SAFETY I)I�'ISION (sure, ori.certificate of Workers'Compensation insurance,or certified copy thereof(Sec.3800.Lab.C'.). olicy No. Company FOR APPLICANT TO FILL IN BUILDING 1 ADDRESS iy Certified copy is hereby furnished. `� BUILDING 57 L�3 o5-e - LOCALITY 7C ADDRESS 1 ] Certified copy is filed with the county building inspection' ` LOCALITY Te 1 p ( , V - NEAREST ST. department. late Applicant NEAREST r n S DISTONo. GUP TYPE P CESSED BY CROSS ST. �+'� 5 W/t lA a�rij CONST.J/j/�/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK NOP (COIR HWCLAY E) STATE MAJOR SECOND LOCAL NO. OF BLDGS. Chis section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS y the permit is for one hundred dollars (5100) or less.) USE OF SIZE OF LOT EXISTING BLDG. certify that in the performance of the work for which this - ermit is issued, I shall not employ any person in any manner OWNER C IC NI&S MeL ®iate as to become subject to the Workers' Compensation Laws, r14AIL Zp _ ntOCCUPANCY GROUP ADDRESS O JI Applicant x TEL. Q2 _b63,? OCCUPANT LOAD JOTICE TO APPLICANT: I., after making this Certificate of CITY l T No. 6y6_Z xemption, you should become subject to the Workers' APPLI ANION FOR EXIT HARDWARE.ompensation provisions of the Labor Code,you must forth •Ith comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. eemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ® Panic Devices hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) (commencing with Section 7000) of Division 3 of the Busi- No. of EXITS ess and Professions Code,and my license is in full dirge and ffect. PARKING REO D D PROVIDED SPACES icense Number Lie. Class LIMITED TIME USE ontractor Date DATE DATE rpom: I am exempt from the licensing requirements as 1 ant a - licensed architect or a registered processional engineeraIZE of NO. OF INSPE TOR'S acting In my professional capacity ISertion 7051. Bit,;- "XISTING BLDG. STORIES SIG TORE iness and Professions Code). PP.ESE P:T USE OF BUILDING FINAL APPROVAL .ic.or Reg.No. Date -__— y HO\IL- OWNER-BUILDER DhCI_-%RATION NO. OF EXISTING BUILDINGS ON LOT AND USE II hereby affirm that I am exempt from the Contractor's V �1 009EE 5/12/98 icense Law for the foliowing reason (Section '()31.5. Busi l 1� ()() 1 AN 8:26less and Professions Code): NO. PARKING ` SPACES PROVIDED ] 1, as owner of the properly. will do the wort, and the structure is not intended or offered for sale (Section 7044.Business and Professions Code). ------ -- -- CONS'IRUCTION LLNDING \G1 NC) PROPOSED USE OI- BUILDING hereby affirm that there is a construction lending agenc} 1 S54to or the performance of the work for which this permit t, ;sued(Sec. 3097.Civ.C.). .ender's Name -- PROPOSED MAX. OCC. .ender's Address tPEMITFEEcertify that I have read this application and state that the •hove information is correct.I agree to comply htilli all County UANCE)rdinances and State laws relating to building construction.Ind hCTeby authorize representatives of this County to enter TAL FEE Ipcn the above mentioned property for inspection purposeb. y S Sl I RIA 1161. 1.OR I"VILANATORY LA74GUAGE Signature of Permittee Date