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Home My Public Portal About5755 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATIC:4 DECLARATION i 76M444 p� p p p g�� {�pLp )q ®vr� p q T q CE 875(2-80) Y�fs ��CE16..lrc,P` N/,EQ.' US�i"OPPLICA 1 9®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 i a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING�7� ADORES5d' 7tii�4i1 Certified copy is hereby furnished. UILDING tW L / ❑ AO DRESS .� LOCALITY-1 Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. Date Applicant AREST DISTRICT N GR UP TYPE PROCESSED BY CROSS ST. f� /n� �� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL .ly0 COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY >- (This SBCtIOn need not be completed if the work involved O NO. OF BLD GS. TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS Noq (CIRCLE) STATE MAJOR SECOND LOCAL U by the permit is for one hundred dollars ($100) or less.) uSE OF SIZE OF LOT EXISTING BLDG. cc I certify that in the performance of the work for which this I 0 permit is issued, I shall not employ any person in any mannerOWNER s`s so as to become subject to the Workers' Compensation Laws. OdAIL �v OCCUPANCY GROUP W ADDRESS CL N Date Applicant / NOTICE TO APPLICANT: If, after making this Certificate of clTv �� NLlyio D OCCUPANT LOAD Z Exemption, you should become subject the Workers' APPLI ATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,, you must forth- with comply with such provisions or this permit shall be TRAILER USE F] GEOLOGY INSPECTION No Spec. KnOWI. ❑ deemed revoked. P LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION El 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 BusiIF - ness and Professions Code, and my license is in full force and effect. l 1 PARKING REq'D � PROVIDED D i SPACES License Number Lic.Class i LIMITED TIME USE Contractor Date G S" Jam/ DATE DATE ❑ I P M: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF OF11.6 INSP OR's acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. TORIES sl TORE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date �' HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS O 3 �•—•:I-.•1 N .i__E 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 C _ _i: •� I;^i _ +:.1: 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). ROPOSED 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. Lender's Address PERMIT FEE I certify that I have read this application and state that the l above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, i s and'hereby authorize representatives of this County to enter T6TAL FEE :5 the above-mentioned property for 'nspec 'on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 1 Signature mit 7 to i WO COMPENSATION DECLARATION CE 875(71-84) MISCELLANEOUS APPLICATION 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 ' a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING f n /• ADDRESS Certified copy is hereby furnished. ADDRESS ,',S LOCALITY 1 ❑ Certified copy is filed with the county building inspection LOCALITYv City NEAREST department. Temple CROSS ST. /vrjL( Date Applicant NEAREST DISTRICT NO GR P TYPE CESSED BY CROSS ST. CONS I CERTIFICATE OF EXEMPTION FROM WORKERS' DESCRIPTION LOT NO. BLOCK MAP HIGHWAY COMPENSATION INSURANCE 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.) USE OF T SIZE OF LOT I EXISTING BLDG. I certify that in the performance of the work for which this prLppc.L ty permit is issued,I shall not employ any person in any manner owNER v so as to become subject to the Workers' Compensation Laws. MA OCCUPANCY GROUP c MAIL yy�� "ed R/ i ADDRESS J% O� ` 0 I Date applicant TEL. A y NOTICE TO APPLICANT: If, after making this Certificate of CITY (f--LrNo. ala OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICA–ION =0R EXIT HARDWARE:provisions of the Labor Code,you must forth- I with comply with such provisions or this permit shall be IT--.--- USE _ GEOLOGY INSPECTION No Spec. Knowl. u deemed revoked. f r n Panic Devices L.J OCCUPANCY INSP'cCTION _� I � LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions o:Chapter SAFETY PERMIT = (LIST ITEMS 9EL0't.') I ' 9 (commencing with Section 7000) of Division 3 of-.he Busi- No. OF EXITS ' ness and Professions Code.and my license ism :ull force and — PARK f efect. IVG REO ° PROVIDED ! I f 1 SPACES L--� License Number Lic. Class LIMITED TIME USE Contractor Date SATE DATE 1 FgOM: TO: ElI am exempt from :he licensing -equirements as I am 1 INSPECTOR'S I t licensed architect or a registered professional en;inee. I SIZE OF INC• CF SIGNATURE acting in my professional --oacity iSection '0=i. Bu.- I EXISTING BLDG. STORIES iness and Professions Codej. FINAL APPROVAL PRESENT USE OF BUILDING Iz l�"Go Lic.or Reg.No. Date 1 I HOME OWNER-BUILDER DECLARATION NO. OF EXISUSE BUILDINGS VV 1 hereby affirm that t am exempt from the ContractorON LOT AND s T License Law for the following reason (Section -031.5. Busi- ness and Professions Code): No. PARKING /� I /I I. as owner of tSPACES PROVIDED he property, will do the work and the structure is not intended or offered for sale (Section 7044,Business and Professions Code). V PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY6 I hereby affirm that there is a construction lending agency OgMf(h1 Ore for the performance of the work for which this - i issued(Sec.3097,Civ.C.). ' Lender's Name PROPOSED MAXt�OCC. Lender's Address T I PERMIT FEE 25.0063 I certify that 1 have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ' ) t ordinances and State laws relating to building construction, 1 and hereby authorize representatives of this County to enter TOTAL FEE 25.00 Tw upon the abov mentioned prope inspection purposes. I SEE REVERSE FOR E.I[PLANATORY LANGUAGE Signature of Permitte Date =- t_ I )