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Home My Public Portal About5785 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) W SC E L ISA N EO U S APPLICATION I hereby affirm that I have 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 APPLICANTTO FILL IN BUILDING r n�qT � J 1� ADDRESS ❑ Certified copy is hereby furnished. nocREss fGySP t!+{y KL LOCALITY ❑ Certified copy is filed with the county building inspection I��444 NEAREST department. LOCALITY CROSS ST. Date Applicant NEAREST DISTRICT NO. GFFFUP TYPE P ESSED BY CROSS ST. ' t0 OIAO%� CONsT. l� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ,tlJ a COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY } NOOF LOGS. No! (CIRCLE) STATE MAJOR SECOND LOCAL d (This section need not be completed if lite work involved TRACT NOW. ON BLOT USE ZONE SPECIAL CONDITIONS OU by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. ' 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 V I' so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP ' LU ADDRESS t90 l�MAIL :A M Date Applicant Cn it NOTICE TO APPLICANT: If, after making this Certificate of CITY �gn NOL.' 73"/—IPa 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 DeVIC@S ❑ 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 � e sG pp RKING. effect. % l REO'D O PROVIDED D I �- SPACES License Number Lic.Class LIMITED TIME USE Contractor Date DATE 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 in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING ,f FINAL APPROVAL / •�"'-[��[ Lic.or Reg.No. Date NO.OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION ON LOT AND USE I hereby affirm that- I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Susi- ; /'• 'T. ness and Professions Code): NO. PARKING SPACES PROVIDED ❑ I, as owner of the property, will do the work and the structureis not intended or offered for sale (Section I� 01 4 7044, Business and Professions Code). PROPOSED USE OF BUILDING 1+. CONSTRUCTION LENDING AGENCY ��WIIJJ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is '.ssued(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 195UANCE FEE ibove information is correct.I agree to comply with all County ardinances and State laws relating to building construction, 71OTAL FEE and hereby authorize representatives of this County to enter upon the above-men I dp op rty for ins pecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pe ittee Date • 'WORKERS'COMPENSATION DECLARATION CE875a(tt.ea) MISCELLANEOUSAPPLICATION 1 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 ADDRESS Certified copy is hereby furnished. QUILDING Q LOCALITY fADDRE3S S 7U S K, S& 17lt LVD ECertified copy is filed with the county building inspection 1 OCALITY C� Vis' jr C CROSS department. bur ST. Date Applicant NEAREST / �/Q� Kn DISTN¢, GRJ*JP TYPE ESSED BY PP RR"-'"+!� ZV+"ry'- ®/�) Orft/ +'/�y CONS CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. S LEGAL f COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLET (This section need not be completed if the work involved TRACT NOW OON LOT S. USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF �2 SIZE OF LOT EXISTING BLDG. v_ I certify that in the performance of the work for which this /fir o permit is issued,I shall not employ any person in any manne�X' OWNER of buildingA'L AC' (/fVe.(T so as to become subject to the Workers'Compensation Laws. MAIL /J _ .—, Z x OCCUPANCY GROUP o ADDRESS '?4J come, .SI �'��I.J V Date Applicant ul NOTICE TO APPLICANT: If,after making this Certificate of CITY 5r NO. ��%--��,� iii 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. LICENSED CONTRACTORS DECLARATION OCCUPANCYPanic Devices INSPECTION❑ 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS 9ELow) 9 (commencing with Section 7000) of Division 3 of the Bu�si- -� NO.OF EXITS ness and Professions Code,and my license is in full force a,�,'��[�[ :l effect. Name of business PARKING REQ ID PROVIDED n License Number Lic. Class <* 1 G I-?(;I!(-A& SPACBS ' � - LIMITED.TIME USE Contractor Date I �� `( I rpt}L �V 4 T.c rfifJ�V �v� i' DATE DATE I FROM: TO: Ell am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer I SIZE OF NO.OF INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL y Lic.or Reg.No. Date PRESENT USE OR BUILDING f ti HOME OWNER-BUILDER DECLARATION j NO. OF EXISTING BUILDINGS r� (� -A 91,II_a F"11 ON LOT AND 99E I �I�1 1 hereby affirm that I am exempt from the Contractor's �l License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): I NO.PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED 5-} a 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 ' 1 certify that 1 have read this application and state that the I. PERMIT FEE 25.00 1 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 • upon theab mentioned property for inspection purpjfies. I SEE REVERSE FOR EXPLANATORY LANGUAGE xx /t 7KI Citnre nr pPrmifft f. Date