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Home My Public Portal About5745 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 CE 875(11-84) MISCELLANEOUS APPLICATION o I $erebaffirm that I have a certificate of consent tself COUNTY OF LOS ANGELES iUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800 Lab.C.). Policy Company �:� 141oi ,0 FOR APPLICANT TO FILL IN BUILDING /J �J ,Z8,5-O/4 1 ADDRESS �/,� AtI. Certified copy is hereby furnished. BUILDING /y LoICALITY ADDRESS 7/ DCertified copy is filed with the county building inspection LOCALITY /� NEAR EST department. / CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE CON T. PROCESSED BY CROSS / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o V �l�L• COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY OR BLD GS. STATE MAJOR SECOND LOCAL NO. (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS NO. 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./ 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 C3 ADDRESSh-• Date Applicant i LLI NOTICE TO APPLICANT: If, after making this Certificate of CITYC No. (� O OCCUPANT LOAD z 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. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E] 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 i No. OF EXITS ness and Professions Code,and my license is in full force and ^I I effect. D PARKING REQ'D PROVIDED —J SPACES J i .License Number Lic. Class I � 1D(' LVok � ►. - LIMITED TIME USE Contractor Date �� DATE DATE FROM: To: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE of No. oP INSPECTOR'S acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES sIG TUBE iness and Professions Code). ✓ ` FIAIAL APPROVAL �" <•x. PRESENT USE OF BUILDING Lic.or Reg.No. Date '"-- y HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I �j I hereby affirm that I am exempt from the Contractor's g� .y►t'" -F..!.I:?`•..i_!4(. .. .'.'• ':%'; License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED 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). •y PROPOSED USE OF BUILDING ' CONSTRUCTION LENDING AGENCY 1 I hereby affirm that there is a construction lending agency 1 for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name PROPOSED MAX. OCG. Lender's Address ou '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 thea e-mentioned roper nspec tion purpos : � 3D S EE REVERSE FOR EXPLANATORY LANGUAGE E� Signature of Pxmittee Dat //•grloxrvec— WORKERS'COIvPENSATION DECLARATION CE 875(11-84) M ISCFLLANEOUS APPLICA�TIO�V 'fl I ltcieby affi?'m that I have a certificate of consent to selfCOUNTY OF LOS ANGELES BUILDING 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 ABUILDIDDRENG��V t SS a Certified copy is hereby furnished. BUILDING �.7,/C 1m LV6 ADDRESS '7J LOCALITY FICertified copy is filed with the county building inspection LOCALITY Ck' NEAREST department. CROSS ST. Date Applicant NEAREST Lof DISTRI T NO. GROUP TYPE CESSED BY CROSS ST. Y., �f "T� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL !Ja v COMPENSATION INSURANCE DESCRIPTION LOT NO. BLO GK MAP HIGHWAYNO. OF SLOGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL (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. ' Dom•, 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 QF 1h;Id so as to become subject to the Workers' Compensation Laws. +MAIL OCCUPANCY GROUP a ADDRESS TO Vb 1--' Date Applicant LLI NOTICE TO APPLICANT: If, after making this Certificate of cITYr_ �S (tel^rTio 3 571 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 ❑ 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 Al �LS ^' I effect. PARKING REQ'D �J PROVIDED S �� SPACES JJ License Number Lic. Class /U{/ 1/ LIMITED TIME USE Contractor Date DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE iness and Professions Code). PRESENT USE OF BUILDINFINAL APPROVAL BUILDING FINAL Lic.or Reg.No. Date 0� HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS /- 2- r INEE � L- L.E ON LOT AND USE .� I hereby affirm that I am exempt from the Contractor's �7y1 License Law for the following reason (Section 7031.5, Busi ness and Professions Code): NO. PARKING SPACES PROVIDED A" 'C' I, as owner of the property, will do the work and the 4 1 AM 9-'15 I-I structure is not intended or offered for sale (Section 7044,Business and Professions Code). PROPOSED USE of BUILDING &124L L 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.Q. 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 V Q upon the ove-mentioned property f�inspec�tioTes.t� SEE REVERSE FOR EXPLANATORY LANGUAGE 1• WORKERS'C0MPENSATIONDECLARATION 76M4" 5(tn-84) M ISCELLANEOU-S APPLICATION r- ,1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION i ! insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). RUILDING L FJ Policy No. Company FOR APPLICANT TO FILL IN tDDRESS Certified copy is hereby furnished. I GU A.OR NG 0 ADDRESS '� LOCALITY Certifdepaied copy is Sled with the county building inspection LOCALITY t. Temple City` " CROSS sT. Date Applicant NEAREST /�� DISTR�N GRO P TYPE ESSED BY CROSS ST. (lJj CONST. } CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. HLOCK +IAP HIGHWAY STATE MAJOR SECOND LOCAL NO. OF HLD GS. (CIRCLE) (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 (5100) or less.) I usE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this JViLlikaJ permit is issued, I shall not employ any person in any manner OWNER S , n C so as to become subject ro the Workers' Compensation Laws. MAILOCCUPANCY GROUPE;K] _ ADDRESS V j?y ® 1 1 bD i Date ApplicanttV 2 NOTICE TO APPLICANT: If,after making this Certificate of CITY Q� i Pq O NOL 61 � �j`O ' 337 OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth-with comply with Such provisions Or this permit shall be TRAILER USE 1__1 GEOLOGY INSPECTION No Spec. Know!. deemed revoked. _ LICENSED CONTRACTORS DECLARATIONOCCUPANCY 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 REOD PROVIDED S"'A CES o License Number Lic. Class LIMITED TIME USE y Contractor Date DATE DATE W r'ROM: TO: INSPECTOR'S H I am exempt from the licensing requirements as I am a x ( licensed architect or a registered professional engineer SIZE OF NO.OF SIGN TORE Z acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES m iness aind Professions Code). �� O PRESENT USE OF BUILDING FINAL APPROVAL oe U Lic .or Reg.No. Date Q ) . HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I� S 1 hereby affirm that I am exempt from the Contractor's I q/V•/ i License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered ibr sale (Section 1 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction leading agency a Rd 4; for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. I_ Z Lender's Name )¢� PROPOSED MAX.OC Lender's Address I PERMIT FEE 25.00 >:;i I certify that I have read this application and state that the I. above information is correct.I agree to comply with all County i ISSUANCE FEE I.I ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25.00 '• °) upon the above- ntioned property for inspection purpos SEE REVERSE FOR EXPLANATORY LANGUAGE T11 • (, 1 i Signat of Per ttee Da e