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Home My Public Portal About5773 ROSEMEAD BLVD_Miscellaneous__ (WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby a cert that I have a 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. ADDRESS BUILDING LOCALIT Certified copy is filed with the county building inspectionLOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. I G OUP TYPE CESSED BY CROSS ST. [J CONSTJ/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a I' COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. OF NO. (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT S. USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. '-.;4 >I.-- I 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 so as to become subject to the Workers' Compensation Laws. MAIL — OCCUPANCY GROUP o ADDRESS C~ Date Applicant w NOTICE TO APPLICANT: If, after making this Certificate of N OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATI N FOR EXIT HARDWARE: _ Compensation provisions of the Labor Code,you must forth- with comply with such provisions oI this permit shall be TRAILER USEGEOLOGY 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 effect. PARKING REQ'D = PROVIDED o SPACES License Number Lic. Class a bi B LIMITED TIME USE Contractor Date DATE GATE FROM: TOI D I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE of (.: ;"a rINr4PE•C•TOR'S acting in my professional gcapacity (Section 7051, NO. OFUS- EXISTING BLDG. STORIES = sYGnTeTURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date J •,•• _ Al HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS D �� w! _ _ •" ON LOT AND USE I hereby affirm that I am exempt from the Contractor's , I License Law for the following reason (Section 7031.5, Busi- ness usiness and Professions Code): NO. PARKING 7' El1, 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 PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE B-G 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 �/�-oo upon t a ,, t• Zd operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ermittee Date ► WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION 1 hereby affirm that 1 have a certificate of consent Compensation self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �1 insure, or a certificate of Workers'Copensation Insurancc e,or ;I a certified copy thereof(Sec.3800,Lab.Q. _ J Policy No. Company FOR APPLICANT TO FILL IN 13UILDING ADDRESS Certified copy is hereby furnished. BUILDING JC�'71 Cscro&gw ;By-vb LOCALITY ADDRESS G Q 0 department.copy is filed with the county building inspection LOCALITY Temple City Ross sT. Date Applicant NEAREST r C� V, CON DISTRI T 1,7UP ITYP / ESSED BY CROSS ST. -rel •IV/v�Iv �dl CO CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (/OOO COMPENSATION INSURANCE DESCRIPTION I LOT NO, el ocx MAP HIGHWAY stare MAJOR SECOND LOCAL NO. OF BLOGS. t1 O. (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 ($100) or less.) USE of 1 SIZE OF LOT EXISTING BLDG. / I certify that in the performance of the work for which this LJJLLPkP=.L Ly permit is issued,1 shall not employ any person in any manner OWNER J5. 'Lew so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS -5 ® L�O I Date Applicant _ NOTICE TO APPLICANT: If,after making this Certificate of ciTYSQAJ 76 Ivo 3 OCCUPANT LOAD Exemption, you should become subject to the Workers' 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. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONa Panic Devices I 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 SPACES REq'D PROVIDED 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 engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S GNATURE iness and Professions Code). I FINAL APPROVAL a �� Lic.or Reg.No. Date PRESENT USE OF BUILDING V 2- HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE V I O I (q.rny�.•• Pyl•y0 { I hereby affirm that I am exempt fmnl the Contractor's � IJ}.@Illr"VFJSJ3.1 1.�YI.L-r^•V' I 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 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 1 hereby affirm that there is a constriction lending agency 13 6F 7- 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 ') I certify that I have read this application and state that the PERMIT FEE 25.00 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 25.00 .41 I up above-mentio ed pro erty for ins ection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date