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Home My Public Portal About5779 ROSEMEAD BLVD_Miscellaneous__ ` WORKERS'COMPENSATION DECLARATION I 8 4 CE (2-80) MISCELLANEOUS APPLICATION CE 87 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 Insurancc e,or , a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN ❑ ADDRESS 7 Certified copy is hereby furnished. Bu1LDING (j /�qw ( f �J ❑ Certified CO ADDRESS RD✓`-l', " 2L✓� S��/C ,fG� LOCALITY copy is filed with the county building inspection NEAREST department. LOCALITY ?� i7(� �q �+� CA 9� 7op0 CROSS ST. Date Applicant NEAREST ��Q� �� / �� r / DISTRICT NO. GROUP TYPE PR CESSED BY CROSS ST.�I✓ �rJ �I 7J A0.7 rD� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL d COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY No. NO. OF BLDGS. (CIRCLE) STATE MAJOR SECOND LOCAL tl.(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS OU by the permit is for one hundred dollars ($100) or less.) USE of cc SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this oic 0. O permit is issued, I shall not employ any person in any manner OWNERspy ?� � V so as to become subject to the Workers'Compensation Laws. MAIL OCCUPANCY GROUP _ W ADDRESS t1: Date Applicant to NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. OCCUPANT LOAD � Exemption, you should become subject tc 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. Panic DBVICBS ❑ 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 PARKING. effect. . REq'D O PROVIDED O SPACES License Number Lic.Class LIMITED TIME USE Contractor Date o wT c 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 to my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIGN TURE iness and Professions Code). PRESENT USE OF BUILDING ,Z/`� FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS 04Igl ON LOT ANO USE C 1 y!e, ,,: 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 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). PROPOSED USE OF BUILDING 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.C.). Lender's Name yyP 1ROPOSED MAX. OCC. Lender's Address PERMIT FEE -AI &L��L/ 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 �Q and hereb a rite representatives of this County to enter , up the X LMpen ioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE APT Signature of Permittee Date WOR KERS'COM PPNSn'1'ION DECLARATION CE 875(71.841 MISCELLANEOUS APPLICATION CE 875 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 Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No.____ _._—Company_— FOR APPLICANT TO FILL IN ADDRE5 Certified copy is hereby furnished. �( X}.� -Bi+lt-D-ING� y71 � � LOCALITY ` AnD�s E] Certified copy is filed with the county building inspection ��Y ¢/ / r, NEAREST department. J XV. ) ( (me. �.i• C.a.. ST. D:IIC____—__ _ Appllcallt—__—_--_ ^ NEAREST DISO�No. UP CONST P CESSEDBY .R 0S ST. ITYPE C ERTIFICATIi OF EXEMPTION FROM WORKERS' LEGAL CORiPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK FAANNOP HIHWAY HIGH LE) STATE MAJOR SECOND LOCAL O. OF BLDGS. (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. 1 certify that in the performance of the work for which this c3 permit is issued, I shall not employ any person in any mannelk OWNER O in i w1 as to heconre subject to the Workers' ('ontpensation Laws. -MAIL OCCUPANCY GROUP C7 ADDRESS G1 6SZ��' �`�JV1/I�[iV�r goUC�frAr ,,J Date_—_--- Applicant -- — ul NOTICE 1'0 APPLICANT: If, after making this Certificate of CITY � � NO" �S 'Z—663 g OCCUPANT LOAD N_ Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: C•ompensatiolr provisions of the Labor Code,you must forth- ❑ with comply with such provisions or this permit shall be TRAILER USE j] GEOLOGY INSPECTION O No Spec. Knowl. deemed revoked. OCCUPANCY INSPECTION j] Panic Devices ❑ LICENSED CONTRACTORS DECLARATION 1 hereby affirm iliat I am licensed tinder 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 an!kX _bu-s le r effect. /\ O ��+`� �"�`g PARKING SPACES REWD 1 PROVIDED 1 License Number _ Lic. Class Cf Cf as 1 LIMITED TIME USE Conlractur--_ _. ___ __—Date__ —_— DATE P ,�•yDATE FROM: TO: I:'lh J? I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S TURE actin in m professional Capacity (Section 7051, Bus- EXISTING BLDG. STORIES ; g YP _ •- iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING 2�✓ g,L�{jl; �'tf; , Lic.or Reg.No.__—.___— _ Date — I TTTTLLLi°°°°ss IIOM1:OWNER-1311ILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I I hereby affirm that I :um exempt from the Contractor's rJ, Licence Law for file 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 for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OP 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. I.elydcr's Address_____ ___ -_——_- — 25.00 I certify that I have read this application and state that the PERMIT FEE above information is correct.1 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 i upon the above- rell tioned ropert y for inspection purposes. SEF.REVERSE FOR EXPLANATORY LANGUAGE • . Ciro 011rP nI Pry 111111Pr - — Date WORKER``J'GY3N1Yh1VJAilV1V 171n47 HKRt1V1Y 20-O0S3DPW72/90 1TJt1A-0 A- A.A--4A LJL llirl-WVA„r A 1,1 x I hereby"affirm that I havea certificate of consent to self COUNTY OF LOS kA GELES : BUILDINGS AND SAFETY DIVISION • (.I'insure,or a eettificate'of.Wbr'kers'Compensation Insurance,or I a eertlfied copy thereof(Set~ 3800,Lab.C.),* Policy No. Company FOR APPLICANT fi0 FILL IN BUILDING UILDING ADDRESS ADDRESS '.I R Certified copy-is•hereby.furnished g77 �s2d �� LOCALITY Certified copy is filed with the county building inspection zip i department. `(ernA C i-.' IJ-790 NEAREST. Date �' v. Applicant SIZE OF LOT NO.OF BCDGS.NOW ON LOT DISTRICT OSS •NO. GROUP TYPE PROCESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS' CONST. 0. COMPENSATION INSURANCE TRACT BLOCK LOT NO. MAP #11GMWAY completed if the work involved "'o• (CIRCA--) STATE MAJOR SECOND LOCAL.. (This section need not be com p ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS � by the permit is for one hundred dollars ($100) or less.) • I certify that in the performance.of the work for which t s e� 1.�I99z o73 permit is issued'I shall not emplW any person in any mann so as to become subject to the Workers Compensation Law. °DRESS te OCCUPANCY GROUP 3 a v i a i Date Applicant , cITY ZIP [:::a •—• NOTICE TO APPLICANT. If: after making this Certificate a ere Par Gq I OCCUPANT LOAD of Exemption. you•should become subject to the Workers' APPLICATION FOR Compensation provisions of the-1*1ior Code.you must forthwith EXIT HARDWARE: comply with such provisions or this permit shall be deemed TRAILER USE 0 GEOLOGY INSPECTION❑ No Spec.Knows. ❑ revoked. Panic Devices ' LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ I hereby affirm that I am licensed under provisions of Chapte : SAFETY PERMIT❑ (LIST 1TF.M3 BELOW) 9(commencing with Section 7000)of Division 3 of the BusitieNO.OF EXITS and Professions Code.and my license is in full force and effec ame o us ess 'e❑ `o �n t PARKING• j' I REO'p L� PROVIDED I I License Number Lit Class sPAces I Contractor Date LIMITED TIME USE 1 1 ❑ I am exempt from the licensing requirements as I am a DATE DATE IFROM, TO; licensed•architect or a•registered professional engineer acting in my professional capacity(Section 7051,Business SizE OF I NO.OF INSPECTOR'S and Professions COde). EXISTING BLDG. OJ $ E O STORIES SIGNATURE-, LIC.or Per,No. •- Date PRESENT USE OF BUILDING FINAL APPROVAL HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am'exempt from the Contractor's License Law for the following reason (Section 7031.5. Business and I Professions Code)- NO.PARKING . ,SPACES PROVIDED. iEl I. as owner of the property, will do the work and t structure is not intended or offered for sale(Section 704 ROPOSED USE OF BUILDING Business and Professions Code). i CONSTRUCTION LENDING AGENCY SB��In S�Gur9 S y'C$n► ui e } I-hereby affirm that there is a construction lending agency for t f d r a the performance of the work for which this permit is issued 1 (See.3047,Civ.Q. PROPOSED MAX.OCG , ' lender's Name PPLICANT(p'w' TEL NO. Lender's Address DORESSn Q/l7 7.!1.73 j I certify that I have read this application and state that the un f6hicv Drs un /�aY� C/� 1/75f" above information is correct I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,dnd hereby authorize representatives of this County to enter upon ISSUANCE FEE the about-mentioned property for inspection purposes. • TOTAL FEE ' $ ✓�_ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date I WORKERS"COMPENSATION DECLARATION 176M444 CE 875 (11.841 MISCELLANEOUS APPLICATION CE 87 1 hereby affirm that I have certificate of consent tself COUNTY OF LOS ANGELES BUILD I-NG -S-I�F'ETY DIVISION insure. or a certificate Workers'of Compensation Insurancc e.or - a certified copy thereof ISec.3800.Lab.C.). _ �• Policy No. Company FOR APPLICANT TO FILL IN BUDREILDING ADSS Certified copy is hereby furnished. BUILDING Jam/ l�SZ/r1 t'f� /3L ADDRESS LOCALITY sm;o� t Certified copy is tiled with the county building inspection LOCALITY NEAREST V!' department. Temple City CROSS ST. Date Applicant NEAREST T D DISTRICT N�l. Go P TYPE P CESSED BY • CROSS ST. Las (UYt Rese)�e-a I CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL1 (/O COMPENSATION INSURANCE ' DESCRIPTION LOT NO. I BLOCK (.AP HIGHWAY 1 ND. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be Com lered if the work involved NO. OF SLOGS. p i TRacT NOW ON LOT USE LONE SPECIAL CONDITIONS by the permit is for one hundred dollars IS100) or less.) USE of i I SIZE OF LOT EXISTING BLDG. I certifv that in the performance of :he work for which :his / _ permit is issued. I shall not employ any person:n any manner OWNER L C so as to become subject to the Workers" Compensation Laws. XL MAIL �D� OCCUPANCY GROUP -_ ADDRESS Date Applicant - NOTICE TO APPLICANT: If.after making ::lis Certificate -it XI cIT� � E�jr(� NoL 3 OCCUP4N-LOAC Exemption. you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APDLICATICN c•? Z(p 5 333 EXIT H.QRC411aRE with compiy with such provisions er :his -hermit shall be -RAILER LISE n GEOLOGY INSPECTION No Spec. Knowl. El deemed revoked. J LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$ Panic Devices I hereby affirm :hat I am licensed under provisions of Chantern SAFETY PERMIT LJ LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 at file Busi- No, of EXITS ness and Professions Code. and my license is in full force and effect. PARKING REO O I 1 PROVIDED S P G C E 5 � License Number Lic. Class LIMITED TIME USE y Contractor Date DATE DATE W H l am exempt from the licensing requirements as I am a TO: m t licensed architect or a registered professional engineer SIZE OF vc. of INSPECTOR'S z acting In :ny professional _ail lt: Se:ilUlh �Ih:1. BITS- EXISTING BLDG. 3TOR1=S SIGNATURE a mess and PrOIe5S1Cn5 Codel. PRESENT USE OF BUILDING p FINAL APPROVAL v LIC.or Reg.No. Date HOME OWNI:12-BUILDER DECLAR.\IIUN NO. OF EXISTING BUILDINGS ✓ / ON LOT AND USE I hereby affirm that I am exempt from the Contractor's I License Law for the following reason (Section -031.5. Busi- ness and Professions Code): NO. PARKING ❑ I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section I 7044.Business and Professions Code). CONSTRUCTION LENDING AGENCY g PROPOSED USE OF BUILDING 1 hereby affirm that there is a construction lending agency .SbAl CAR E ap d relaV be c I for the performance of the work for which this permit is I.I q issued(Sec.3097•Civ.C.). -M ,oa Lender's Name S i C PROPOSED MAX. OCC. Lender's Address n nI� 1 1 certify that I have read this application and state that the PERMIT FEE 25.00 I— �—, M above information is correct.I agree to comply with all County I ISSUANCE FEE rgq ordinances and State laws relating to building construction, I�� 1 and hereby authorize representatives of this County to enter TOTAL FEE -� upon the�bovntlonedproperty for inspection purposes. 25.00 Fr? SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date .-� %o 1 `