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Home My Public Portal About5749 ROSEMEAD BLVD_Miscellaneous__ W r1cERS'COMPENSATION DECLARATION S176104 CE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have 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 ADDRESS ❑ Certified copy is hereby furnished. BUIL S7 M( r Gl LOC ALIT ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. Date Applicant EAREST � QC r DISTRICT O. GRppp UP TYPE P ESSED BY CROSS ST. I.�IJ �(,(, ,5' ��IVI= // 2 CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL / J COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAi NO. BL } NO. ,CIRCLE STATE MAJOR SECOND LOCAL d O (This section need not be completed if the work involved TRACT NowCoN LorT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars (5100) or less.) USE OF SIZE OF LOT EXISTING BLDG. IX I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNE +tyiLO j' � so as to become subject to the Workers' Compensation Laws. 'MAIL I/ /�1 nn 7��' P OCCUPANCY GROUP U ADDRESS IOV VI,.Q f` a1P i1 ("eo 0- LU Date Applicant in NOTICE TO APPLICANT: If, after making this Certificate of, crrY 1,(� f�P� h-CA To� Z(3 i/3 .,��L�� OCCUPANT LOAD z Exemption, you should become subject 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 deemed revoked. NOSpec. KnOWi. ❑ Cl Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 and D t' MC T- T. � k � /� PARKING. effect. .SPACES REQ'D PROVIDED License Number Lic.Class AWYM, b Si Vlf SIC y LIMITED TIME USE Contractor Date T J•K. d CL-6'r :GNC DATE DATE 17 FROM: TO: I am exempt from thelicensing 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 SIGNATURE iness and Professions Code). „ , FINAL APPROVAL PRESENT USE OF BUILDING b�L N Lic.or Reg.No. Date r HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS N0 FEE 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 'I 1(/ _ _ ❑ ) SPACES PROVIDED ' i� I qr r �•r i 4,,14;"J".7 I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section I 7044, Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY D �� 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. OCG. Lender's Address PERMIT FEEa.�dU 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, TOTAL FEE and hereby authorize representatives of this County to enter u n t e bove-m4ne� / !i[ YP ses. SEE REVERSE FOR EXPLANATORY LANGUAGE u Signature of Permittee Date WWkERS'COMPENSATION DECLARATION 76M444 ICE 875(2-80)ICE875 hereby affirm that 1 have certificate of consent self insure, or a certificate of Workers' rs'Compensation Insurance, e,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company. FOR APPLICANT TO FILL IN BUILDING ( p pDDRE55 ❑ Certified copy is hereby furnished. BUILD"ADDREI 0 Rel QQIY t/f({ LOCALIT Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant AREST dC DISTRICT O. GR��QQQUP TYPE P ESSED BY CROSS ST. Lrls Itrcrrt,s (/�1l/� 3 CONST. / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL fl/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY } NOI (CIRCLE) STATE MAJOR SECOND LOCAL tl NO. OF BLDGS. (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 ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this �^.,A` 0 permit is issued, I shall not employ any person in any manner OWNE �� L5' so as to become subject to the Workers' Compensation Laws. AIL1 /�/� OCCUPANCY GROUP �� W AO DR ESS 100 Q4 Q'�� SIfe (Ooo 0— U) Date Applicant ( /1 `` NOTICE TO APPLICANT: if, after making this Certificate o CITY 1,e� eRGf�CA 113 '�q& I OCCUPANT LOAD Exemption, you should become subject to the Workers' v APPLICATION FOR I 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 0 No Spec. Knowl. ❑ deemed revoked. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION11 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 and fie.Y -�- p � kp RKING. effect. SPACES REWD O PROVIDED D L License Number Lic.Class dti Lis S LIMITED TIME. USE Contractor Date • +�• • Q v C 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 SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL 3:10 /�,y_ Lic.or Reg.No. Date YR•' �. Fac I NO.OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION j— ON LOT AND USE I hereby affirm that- I am exempt from the Contractor's I D -,•_ i .i z License Law for the following reason (Section 7031.5, Busi- i ness and Professions Code): No. PARKING I SPACES PROVIDED I, as owner of'the property, will do the work and the I Il�ll structure is not intended or offered for sale (Section 7044,Business and Professions Code). 1 PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY D G� I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is �q!� issued(Sec.3097,Civ.C.). Lender's Name I PROPOSED MAX. OCC. I Jl1 Lender's Address PERMIT FEE .rt 00 1 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, TOTAL FEE and hereby authorize representatives of this County to enter I ybove-mepAioned property.for s t' pufposes. SEE REVERSE FOR EXPLANATORY LANGUAGE u n t e Pref" /711 Signature of Permittee Date I '