The URL can be used to link to this page

Home My Public Portal About5751 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 `'' CE 876(„_84) M ISCELL IEOIJS; APPLICATION I hereby affirm that I have a�certificate of consent to self insure, or a certificate of workers'Compensation Insurance,or i COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION u a certified copy thereof(Sec.3800, b.C) Poe i f-(G Policjq.�TC�.c:rbn%any �` � 2tw FOR APPLICANT TO FILL IN BUILDING 1 ADDRESS Certified copy is hereby furnished. ADDRESS �7S�I �aSL'✓NQCtf�[ U LocgLlr ❑ Certified copy is filed with the county building inspection LOCALITY /r �', r� NEAREST department. CRO ss ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE CESSED BY PP CROSS ST. r QRS <U lcl Q� I,L) ' 'n� �.a cONS7./ C.E CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL uQ V COMPENSATION INSURANCE DESCRIPTION LOT NO (GIRCL NO. (CIRCLE) . BLOCK MAP ) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOTUSE 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. C"• a C:) permit is issued,I shall not employ any person in any manner OWNER Cka R droll 4�S AJC. Vc,oL 1O 7file y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o I ADDRES ~ Date Applicant TE �� d� aFe Lc'L+ NOTICE TO APPLICANT: If, after making this Certificate of I' CITY �Otkq goof d,{{l NOL OCCUPANT LOAD y Exemption, you should become subject to the Workers'. 1 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❑ No Spec. Knowl. ❑ deemed revoked. - OCCUPANCY INSPECTION El Panic Devices ❑ LICENSED CONTRACTORS DECLARATION 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 ,r effect. �! l6tib PARKING REQ'D PROVIDED SPACES 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 engineerslzE 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 Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS �/A�\ ON LOT AND USE d 11.�" I hereby affirm that I am exempt from the Contractor's g�/ nm License Law for the following reason (Section 7031.5, Busi- ness usi ness and Professions Code): NO. PARKING El1, as owner of the property, will do the work and the SPACES PROVIDED IJ 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.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address - PERMIT FEE I certify that I have read tl' pp ca and state that the above information is torr ct.I agree to com ly with all County ISSUANCE FEE `•• ordinances and tate ws relating to bu- •ing construction, and h y au r represent es of thi County to enter TOTAL FEE upon he abov tinned pro rt for inspe tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of ermi Date WOIt6LItS'COl11PENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION 1 hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION - insure, or a certificate of Workers'Compensation InsuranceCOUS ,or a •' a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN J BUILDING /— ADDRESS Certified copy is hereby furnished. BUILDINe �—/ LOCALITY XX ADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST department. xx csoss ST. Date _Applicant NEARESTDISTRICT NO. GROUP TYPE P ESSED BY CROSS ST. �.i �jj CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL golf 40 COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO.OF SLOGS. (Tills 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. !!// 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person inany manneRX OWNER Of building --�✓)u�. =' so as to became subject to the W kers' mp�pr�tlona1vs. B ,.MAILo OCCUPANCY GROUP //�/�LJJ Oe S — / ADDRESS 578 �S 1Uc^ I t3 Date Applicant _ u L. NOTICE TO APPLICANT: If,after making this Certificate of CITY ' • f 7�D NO. OCCUPANT LOAD V3 Exemption, you should become subject to the Workers APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you mast forth- ❑ HARDWARE- with comply with such provisions or this permit shall be I TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. 1 IC'!'sNSEU('ON•fRAC"TORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices El 1 hereby affirm that 1 am licensed under provisions of Chapter I SAFETY PERMIT❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000)of Division 3 of the Bust I NO. OF EXITS El ness and Professions Code,and my license is in full force ani, effect. Name of business PARKING SPACES REWD PROVIDED License Number __--__— — Lic. Class LIMITED TIME USE Contractor— — Date OATS GATE 1 am exempt from the licensing requirements as I am a RNOM: 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 SIG TURF iness and Professions Code). FINAL APPROVAL k-21,16 PRESENT USE OP BUILDING I.ic.or ReR.No.__. _______ — Date IIONIE OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE / I hereby affirm that 1 ani exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING ElI, as owner of the property, will do the work and the SPACES PROVIDED I_ structure is not intended or offered for sale (Section 7044,Business and Professions Code). C'ONSTRUC'TION 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.C.). Lender's Name PROPOSED MAX.OCC. Lender's Address 95.00 I certify that I have read [his 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 author' represei}]k�a ives of this County to enter TOTAL FEE 25.00 Upon th wvc-m ti red pr tperty far ins cction purposes. x ----- - XX SEE REVERSE FOR EXPLANATORY LANGUAGE