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Home My Public Portal About5783 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 176M444 i • CE 875 (2-80) 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.C.) Policy No. Company FOR APPLICANT TO FILL IN PR �— ❑ Certified copy is hereby furnished. BUILDING U e�� J� y ,� ADDRESS l "Jy Certified copy is filed with the county building inspection department. LOCALITY Date Applicant NEAREST DISTRICT NO. GROUP ITy PE ESSED BY CROSS ST. S G.L ' _ 1/yI O _ CONST. I� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 6/ COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY �• No. (CIRCLE) STATE MAJOR SECOND LOCAL a (This section need not be completed if the Work involved NO. OF BLOGS. USE ZONE SPECIAL CONDITIONS O P TRACT NOW ON LOT by the permit is for one hundred dollars (5100) or less.) USE OF U SIZE OF LOT EXISTING BLDG. (� I certify that in the performance of the work for which this cc permit is issued, I shall not employ any person in any manner OWNER - �7I'�✓1. H so as to become subject to the Workers' Compensation Laws. MAIL ��ss e X OCCUPANCY GROUP �'� V ADDRESS Vn ! OOr d Date Applicant cA NOTICE TO APPLICANT: If, after making this Certificate of CITY NO 8 OCCUPANT LOAD Exemption, you should become subject to 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. ❑ No Spec. KnOWi. ❑ OCCUPANCY INSPECTION LICENSED CONTRACTORS DECLARATION [:] Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 , ppN KING If�I effect. REa'D E= PROVIDED , _ �A"_ SPACES License Number Lic.Class l /yin L�lk LIMITED TIME USE Contractor Date ,Y3 Blvd. DATE DATE ❑ FROM: TO: I am exempt from the licensing requirements as I am a. 4'Y+� licensed architect or a registered professional engineer SIZE OF o. of I INSPECTOR'S acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. ,� ( STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING ► I Y, FINAL APPROVAL r� J Lic.or Reg.No. Date !/ ((JJ NO. OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION ON LOT AND USE I 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 - ii z= SPACES PROVIDED I, as owner of the property, will do the work and the Pit 4: ty structure is not intended or offered for sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING V 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 PROPOSED MAX.OCC. Lender's Address PERMIT FEE 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 ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter upon thea ve-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE v Signature of PeCAittee Date WORKERS'COMPENSATION DECLARATION 76M444 CE 875(11 84) MISCELLANEOUS APPLICATION MISC A E EOIJ I ATION 1 hereby affirm that I have a certificate of consent to serf COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,nor ' a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN ADDR IE9S5S ADDRESS /O Certified copy is hereby furnished. Bu 1LDINGNG O �� L� LOCALITY XX ADDRESS Certified copy is filed with the county building inspectip n LOCALITY L I1EAREST department. may. 1 P Gt f r.RDss ST. Date Applicant _ NEAREST / � 7 t / N f" f� DIST RI NOd GRgQ;p TYPE CESSED BY CROSS ST. (i / 1.J ! 7 �'-JD,( �+�' CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY No. (CIRCLE) STATE MAJOR SECOND LOCAL W.S. NO.OF (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 I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG, n permit is issued,i shall not employ any person in any manned OWNER of building . LZI)Q & AS509!:: d . so as to become subject to the Workers'Compensation Laws. 2 ,vd'', �I/ //I�� OCCUPANCY GROUPMAIL cr_ ADDRESS S�8 v �7 •'^-`" •✓I V , EW:1 Date Applicant LL NOTICE TO APPLICANT: If,after making this Certificate of CITY fie' �¢. [.� NO. OCCUPANT LOAD Exemption, you should become subject to 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 Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 1 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 Bilsi- NO. OF EXITS ness and Professions Code,and my license is in full force anix Name of business PARKING effect. SPACES I �� 4 REq'D � PROVIDED License Number PAN F�S y��Lic. Class LIMITED TIME USE Contractor Date R AU, C.n� Inp VEn� Er-1 t''"' DATE DATE FROM: TO: I am exempt from the licensing requirements as I ant a licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTORS actin In m y EXISTING BLDG. STORIES SIGNATURE g y professional capacity (Section 7051 Bus- �,.::•. {:•-._ �- iness and Professions Code). FINAL APPRO AL 4,/ Lic.or Reg.No. Date PRESENT USE OF BUILDING i Ii it{� •-I iial j t '! HOME OWNER-BUILDER DECLARATIONNO. OF EXISTING BUILDINGS O N LOT AND USE 'fJ7 .'�t" •I t'!f'(�{ 1 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 EJI, 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.C.). Lender's Name PROPOSED MAX.OCC. Lender's Address 1 certify that I have read this application and state that the PERMIT FEE 9-5.00 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 0 upon the above-mentioned property for inspection purposes. r�"� XX 2 G - SEE REVERSE FOR EXPLANATORY LANGUAGE XX M-dKd SienaUlre of PPrnihire Date WLJKAL`KJ C-Oh1PLISISAIION I)1_('I_ARATION '` " M1bL 7_LLANEOU'.5 APFOLIGATION I hereby affirm that I hate a certificate of con,enl +I, ,ell C'OLIN'fl' OF LOS ANGL U-S BUILDING AND SAFETY DIVISION. . Il insure.or a certificate of Workers'C'onlpen,It;on In,+++tul,•c.ill- .I certified copy thereof (Sec. 1800. Lab. C.) Policy Not ('OI11I1;1111' _ FOR APPLICANTTO FILL 114 LIUILDING BUILDING ADDRESS _,.DRESS ❑ C'erlified copy is hereby furnished. 'r!. —RO je ne QV LOCALITY El Certified copy is filed ,lith tile county building l,l,pc_ton CITY rztp department. T„_�,,/� C_ ,^A C NEAREST r../•d- ` `�1 7O O .-ROSS ST. Date Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CONST. + CL-RI'II•ICAll." OF L•XI_MI9ION I•R0111 WORKI.RS ----- --- — ------ (' C'OMPENSAIION INSURANCE TRACT BLOCK LOT NO. „ar HIGHWAY IaO. ,CIRCLE, STATE MAJOR SECOND LOCAL (This section need not be completed if the %%ork inlldled ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL IRCUEICONDIONS by the permit i% for one hundred dollar% is 11111) ill' lc%s.) --� I ccrlil*y that in the performance III tileuor 6 Ilu lihlrh ThOWNER TEL NO. Thi, OWNER permit is issued. I shall not employ any prnon nl ,1113 116,111jer so as to become subject to the Workers' C'onlpen,ation (.:IRs. ADDRESS OCCUPANCY GROUP I Date Applicant CITY ZIP r NOTICE TO A1113LIC'AN'l: II'. aper milking thl, ('crliliL•:uc OCCUPANT LOAD of Exemption. 3•ou should become subject to the Nkol.kers' APPLICATION FOR Compensation provisions of the Labor Code.you must 101.111 i•ith EXIT HARDWARE: El Comply with such pros ilio s or :Ills permit Shall be det.niell TRAILER USE❑ GEOLOGY INSPECT ION Gl I revoked. No Spec.Knowl. ❑ ' LICENSED C.'ONTR AC l()ItS I)1 ( I.AI(.Ul(1N OCCUPANCY INSPECTION N Panic Devices ❑ hereby affirm that I am licensed Under provi%i nls of (ImIlLer SAFETY PERMIT❑ ILIST ITEMS BELOW, a 9(commencing with Section 7000)of Division 3 of the Business NO.OF EXITS and Professions Code,and my license is in full IUrce and effect. - SARKING• REq'DPROVIDED I ic. D 1_icensc Number ('la„ aPACES - -- - 1 I Contractor Dale -- - -- - -- -- - LIMITED TIME USE 1 ElI ,1111 exempt front the licensing reyllll'Cll,ellll :11 1 :1117 a SROM: DATE TO: DATE licensed architect or it registered prolessional engineer — acting in 111) professional capacity (Section 7051, Ihl,•11cs, srzr of No or INSPECTOR'S ") and Proicssions Code). EXISTING WAX- _ SIt1RILS SIGNATURE Lie. or Reg. Na Date PRESENT USE OF BUILDING ) FINAL APPROVAL 6�� i 1 11011E OWNER-111(111 DI.R DI ( LAR AI ION NO OF'k xIS11NL BUILDINGS -— - - _ - \0\ 1 + ON t-or AND USE L/V A I hereby affirm that I :nn e\enlpl Irons the Contractor's I iLense Law for the following reason (Section 7011.5• Business and + Prole%slons Code):): NO PARKING 'A,I'ti!•RJVlnr.D I. as tmner til' Ile I1IOpe111. %%Ill 1111 the %%oik and the _ " --- - - 1lrlletlll'C 111101 Intended lirIleled I''I Sale(Seel loll 10.1.1, PRUPUSCU USE OF BUILDING �� - ---• I Business and Professions C'o'd' - — I CONSTRUCTION LENDINO AGI NUY hereby affirm that there i1 a construction lending ,1Lelle% I' I' the performance of the %%orb lbr llhich this per117t is Issued - -- ----- - -- { (Sec. 1097.Civ.C'.)• PROPOSED MAX.OCC. P \J � Lender's Name X AIT1 n /� TEL NO. + lender's Address ADDRESS ,{7 -/ / f� I certify that I have read this application and state 111,1: the 9, Z"L-Q_ 7 0 1 above information is correct. I agree to Comply with all C(•inty PERMIT FEE I ordinances and State laws relating to building construction•and hereby authorize representatiVeS of this C'ounly to enter upon ISSUANCE FEE the abov nentionep fur inspection purposes. �t l / TOTAL FEE X 170117- r. REVERSE FOR EXPLANATORY LANGUAGE Signal) a of flenntuee I),le a. 1 CE 875(77-84) Ii/11JtoEz. —1_/`i1VIGVU-0 /-%F— I— L.1%.0 in I IVltl 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 certifiedeof 380 Policy No r r0L `v NLS}' BL DRESS my —r ILDING FOR APPLICANT TO FILL• ADDRESSIN Certified copy is hereby furnished. X BUILDINGS? (�)�IRA A 0W. LOCALITY ADDRESS 77 ' dCertified epartment is filed with the county building inspection LOCALITY Temple City csAoss sr. Date Applicant NEAREST ` /� ( �J f'��r DISTRI T?N GROyP TYP P OCESSED BY I CROSS ST. "�` J TVIN .�x � CONS I CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NIG Mw AY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF SLOGS. (This section need not be completed if the work involved TRACT NOW ON LOT USEZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (S100) or less.) USE OF SIZE OF LOT EXISTING BLDG. 7 I I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner x OWNER lr IV—A L. c so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP �+ , _ w 2� �1'l i_. ]�'k ADDRESS I � i Date Applicant 7 CCCL(L7»��///"` U //��(�TTTT�I TF-1-14 I' NOTICE TO APPLICANT: If,after making this Certificate of X. CITY D1N R0(AZA No. (p"303 (f OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- with comply with such pIov>sions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$$ Panic Devices � i hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) I 9 (commencing with Section 7000) of Division 3 of the Bus- _ NO. of EXITS ness and Professions Code,and my license is in full force and PARKING SPACES effect. SPACES REq D D PROVIDED N I License Number Lie. Class o ) LIMITED TIME USE LL H Contractor Date DATE DATE LUFROM: TO: H I am exempt from the licensing requirements as Tam a m ► licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S Z acting in my professional capacity tSection 7051, Bus- EXISTING BLDG. STORIES SIGNATURE °m mess and Professions Code). FINAL APPROVAL 9 _ O PRESENT USE OF BUILDING r4 0 Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION ON• OF LOT AND USE License BUILDINGS I Hereby affirm that I 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 structure is not intended or offered for sale (Section ) 7044,Business and Professions Code). ' Xi PROPOSED USE OF BUILDING USS{ CONSTRUCTION LENDING AGENCY (� I Hereby affirm that there is a construction lending agency I o..l.l;-- { I for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name I r_la C{–�,.5l.� PROPOSED MAX. OC6,wF Lender's Address ( I PERMIT FEE 25.0U 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 � P Y tY ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25.00 L I upon the bove-mentioned property for inspection purposes. I 1 �yaSEE REVERSE FOR EXPLANATORY LANGUAGE yacr 1 nature of Permittee Date