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Home My Public Portal About5791 ROSEMEAD BLVD_Miscellaneous__ 1vOR CERS'COniPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I liergby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �f a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS bU Certified copy is hereby furnished. ADDROR ESESG O LOCALITY S G/ 0 Certified copy is filed with the county building inspectionOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. [YOUP TYPE P ESSED BY CROSS ST. CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL � COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDG (This section need not be completed if die 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. I certify that in theperformance of the work for which this c permit is issued,I shall not employ any person in any manner OWNER s' so as to become subject to the Workers' Compensation Laws. MAIL �CCUPANCY GROUP _�. o ADDRESS Date Applicant w 13- NOTICE TO APPLICANT: If, after making this Certificate of CITY Ivo ' 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 OI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked. ❑ El Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El 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 RSQ'D PROVIDED SPACES License Number Lic. class - LIMITED TIME USE Contractor Date - e DATG DATE El I am exempt from the licensing requirements as I am a FROM: INSPECTOR'S licensed architect or a registered professional engineer SIZE OF NO.OF acting in my professional capacity (Section 7051, Bus- iness US- EXISTING BLDG. STORIES SIGNATURE inessandProfessionsCode). FINAL APPROVAL ��`/ �� PRESENT USE OF BUILDING Lic.or Reg.No. Date w HOME OWNER-BUILDER DECLARATION NO. OF EXISTINGI�•� BUILDINGS / 41, NO REE ON LOT AND USE f. (n/ I hereby affirm that I am exempt from the Contractor's V License Law for the following reason (Section 7031.5, Busi- i II` lip 13130C.-C-0 sy ness and Professions Code): No. PARKING ��1 1g El I, as owner of the property, will do the work and theSPACES PROVIDED 5099 j, AMID-03-5 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 1, for the performance of the work for which this permit is eg issued(Sec. 3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE d� 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 Stats laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE Oa upon the abov ned pmverty for inspectign purposes. S„ EE REVERSE FOR EXPLANATORY LANGUAGE Sig re of Per ee Date r �� WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION thereby affirm that 1 !lave a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy th F: Policy No. otnpany Mm �- D F AP LICA TO FILL IN BUILDING LDA. ADDRESS �/' ® Certified copy is]hereby furnished. 35a`,�U IDLk L'Nss PiOSe117ead LOCALITY Certified copy is filed with the county building inspection _LO.CALLITY Te 1 le Cit NEAREST department. g�{ I� 3T CRDss ST. Date Applicant NEAREST DIST a�lyp. G UP CON CESSED BY CROSS ST. OOyy CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY No. (CIRCLE) STATE MAJOR SECOND LOCAL !T NO. OF HLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT r0N (TilE 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. O permit is issued, 1 shall not employ any person in any mann SER-of-builc�in ro as to become subject to the Workers' Compensation Law . MAIL OCCUPANCY GROUP LTJ o ADDRESS I" Date Applicant LO NOTICE TO APPLICANT: If,after making this Certificate of CITY TNO. 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. ❑ Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 a 7�7 effect. ✓--tV4 S1ne'S-S Radio Shack #3533 PARKING RVQ'D PROVIDED SPACES License Number Lic.Class LIMITED TIME USE Contractor Date DATB DATH 0 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 SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL 64'e �� •i0 Lic.or Reg.No. Date j , ( HOME OWNER-BUILDER DECLARATION No. of EXISTING BUILDINGS O J �—�Q�� Fa7a� ' 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 I ti 1, as owner of the property, will do the work and the SPACES PROVIDED I structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I thereby 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 applWaltion and state that the PERMIT FEE 25.00 above information is correct.I a to comply with all County ISSUANCE FEE ordi lances and State laws re Ing to building construction, and ereby autlh a rep ntatives of this County to enter TOTAL FEE 25.00 upo hQlhe bov entio property for inspection purposes. I _ ? SEE REVERSE FOR EXPLANATORY LANGUAGE xx Tax Irtana� e.r--xP _x .=10-95 u~ Sign•lure of Pernhittee �— Date