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HomeMy Public PortalAbout5795 ROSEMEAD BLVD_Miscellaneous__ W9RKE12S'COMPENSATION DECLARATION 'cEe�e4(tt-s4) MISCELLANEOUS APPLICATION I hereby affirm itbAtcat I have a certificate of consent to c 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.). I Policy No. Company BUILDI FOR APPLICANT TO FILL IN pUILD1 NG r _ ❑ Certified copy is hereby furnished. BUILDING /f ADDRESS S`79,T iQoSEo� JO�L vp LOCALITY DCertified copy is filed with the county building inspection LOCALITY p NEAREST dC� department. /�✓�'!pG _/ l C. %/•78 CROSS ST. Date Applicant NEAREST // �,/ D'STRICT NO. GROUP TYPE CESSED BY CROSS ST. (� o S U/1/A-5 ��0�' �_ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 4 COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. OF BLOCS. NO. (CIRCLE) (This section need not be completed if the work involved 0 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. 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 G so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP a ADDRESS r" Date ApplicantLL" TE NOTICE TO APPLICANT: If, after making this Certificate of ' CITY NOI. 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 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. I ®• Sl PARKAC RE pROVID ED SPACES License Number Lic. Class • 6105, LIMITED TIME USE Contractor Date DATE DATE F] I am exempt from the licensing requirements as I am a I licensed architect or a registered profbssional engineer SIZE OF NO.OF FROM: TO: INSPE TUREOR s acting in my professional capacity (Section 1EX STING BLDG. STORIES, us- I SI iness and Professions Code). ' FINAL APPROVAL � PRESENT USE OF BUILDING ,i Lic.or Reg.No. Date O T5 HOME OWNER-BUILDER DECLARATION NO. OF EXISTINd BUILDINGS II N_� FEE E , 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 'Y/ i )�;#�'=f_•_3 :%�1= r•. I, 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). I CONSTRUCTION LENDING AGENCY PROPOSED//USE OF BUILDING d I hereby affirm that there is a construction lending agency L,Uld7 ,7N 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 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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �q�' 1•�C.t t� 'C� 117 �•,2C)•QS' , nature of Permittee Date WORKERS'COMPENSATION DECLARATION , 76M444 ` 1. CE 875(2-80) IMU�C.JELLANEOUS APPLICATION I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES UILDING AND SAFETY DIVISION insure, or a certificate of Workea rs'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company ! FOR APPLICANT TO FILL IN 6;u1LDING ADDRESS ❑ Certified copy is hereby furnished. UILDING G b ❑ � I ADDBRESS�,�� eS L L CALITY Certified copy is filed with the county building inspection NEAREST 'department. LOCALITY GROSS ST. Date Applicant - NEAREST �l` ' iJ DISTRICT NO. GROUP TYPE ESSED BY CROSS ST. *51�N � CONST./ , CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK pr HIGHWAY } NO. OF HLDGS. N (CIRCLE) STATE MAJOR SECOND LOCAL d 1 (This section need not be completed if the work involve TRACT NOW ON LOT U E ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less USE OF 7 SIZE OF LOT EXISTING BLDG. / W .1 certify that in the performance of the'work for which this 0 permit is issued,, I shall not employ any.person in any manner OWNER 0 so as to become subject to the Workers'Compensation Laws. ' AIL n, VV�i.`- y� j� i OCCUPANCY GROUP �_ W ADDRESS4©�y C4'UAA "'TI 1G �� I ( O_ Date Applicant rE g NOTICE TO APPLICANT: If, after making this Certificate of iry�� C* 8 G 1 ✓ —g® 6 1 OCCUPANT LcrAD Exemption, you should become subject to the Workers' APPLICATION FOR I EXIT HARDWARE Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION1 C] ! No Spec. Knowl. deemed revoked. ❑ ' ❑ LICENSED CONTRACTORS DECLARATION occurwNcv INSPECTION Panic Devices❑ , I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT V (LIST ITEMS BELOW) NO. OF EXITS a 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. SPACES REq'D O PROVIDED D License Number Lic.Class I' LIMITED TIME USE Contractor Date DATE DATE ❑ FROM: TO: I am exempt from the licensing requirements as I am a. 1 licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. wSTORIES + / NJW4J RE iness and Professions Code.): PRESENT USE OF BUILDING FINAL APPROVAL ���6✓�� Lic.or Reg.No. Date fYa- c HOME OWNER-BUILDER DECLARATION of EXISTING BUILDINGS / iON LOT AND USE v =r I hereby affirm that- I am exempt from the Contractor's �AI iJ �`' ' 9�vf License Law for the following reason (Section 7031.5, Busi- I I �'�°( ; ness and Professions Code): No. PARKING _ ISFACES 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 __ 1/ •1 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.). I Lender's Name ' I PROPOSED MAX. OCC. Lender's Address 'PERMIT FEE 11 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 - and hereby authorize representatives of this County to enter upon.t a above-mentioned roperty for inspection purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date 1 i ' U ,I hereby.affirm that I have.a certificate bf consent to(self COUNTY OF 09 ANG—ES = .BUII;DI1VCi:.ANIt aAb�l Y 1J1'V.1��VlV .+*`insure or a certificate of;Wdr mrs'Compensation Insurance,or `: y ,• „ ;a certfdied copy'thereof (Sed'3800, Lab C);' - - FOR APPLICANT TO FILL IN BUILDING Policy'No. Company I UILDIN[G.ADDRESS ADDRESS •.1 ❑ Certified copy.is:hereby:furnished. I , ]( $I( QS �"� V �� LOCALITY • ❑ Certifietf copy is filed'with the county building inspeciio CITY C ZIP NEAREST. I tiepartment. 1' Teri, e. City 17.90 CROSS ST. Datg r' >- Applicant SIZE OF LOT NO.O'F'BL'DGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY 1.2- 12. S CONST. O CERUFICATE OF•EXEMPTION FROM WORKERS't TRACT BLOCKLOT IVO. 7 ,/o j,1 U COMPENSATION INSURANCE ( 3623 71 71f 7 Mo c11 cLe1 STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work iRVOlived ASSESSOR MAP BOOK PAGE r Z PARCEL I Liss ZONE SPECIAL CONDITIONS I by the permit is for one hundred dollars ($.100) or less.) J :' L cestify'that in the performapce.of the work for which Ith' :�CLSQ.IL . er TEL o. -3 33 permit is issued'11hall not employ'sny person in any mann ADDRESS / �I 1 so as to become subject to the Workers' Compensation L+ws 3 I'22/.it 3 OCCUPANCY GROUP N Z Date Applicant , clrY zIP ' NOTICE TO APPLICANT: If: after making this Certificate 5a i o2 3 76 OCCUPANT LOAD of Exemption, you•should become subject to the Workers' APPLICATION FOR EXIT HARpWARE: Compensation provisions of the-I:alior Code you must forthwith comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ revoked. 1 ❑ OCCUPANCY INSPECTION Panic Devices LICENSED CONTRACTORS DECLARATION I hereby affirm'that I am,licenscd under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) NO. EXITS ❑ 9(commencing with Section 7000)of Division 3 of the Busin e d uslness and Professions Code•and my license is in.full force and eff ct.'.. PARxING Lim Class SPACES ' REQ'D PROVIDED I License Number i Qdr1 I Contractor Date v rat t 0 LIMITED TIME USE 1 DATE DATE ❑ I ani'exempt from She licensing requirements as I am a FROM: TO: licensed•architect or a' registered professional engineer F r NO.OF INSPECTOR'S acting in my professional capacity(Section 7051,BuS111eSS SIZE OFpCISTING BLDG. { Z STORIES SIGNATURE. and Professions Code). , Lim or.Reg.No - Date PRESENT USE OF BUILDING Rel 1 Shop FINAL APPROVAL QL HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS ' ON-LOT MD USE I hereby affirm that I sm-'exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): i ivO.PARIgNG ,I i 2,11 PROVIDED. ❑ I, as owner.of the property, will do the work and ;t structure is not intended or offered for sale(Section 7� , )OPOSED USE OF BUILDING I Business and•Professions Code). 1 'Ra, .; I s,h o i CONSTRUCTION LENDING AGENCY ;' • I'hereby affirm that there is a construction lending agencyfor , the performance of the Work for which this permit is issued PROPOSED MAX.OCG Sec 3097,Civ.C.).. (Sec. A LIC°AN ( S Name TQFW) TEL NO. Lender's Address ( DDRESS I certify that-1 have read this-application and state that the = e vt �,•6ltii/1ded IF/ 71 above information is correct. I agree to comply with all County i PERMIT FEE •, - ordinances and State Ilsws kelating'to building construction,acid hereby authotiDe''representatives.of this County to enter upon ISSUANCE FEE the above-mentioned property for inspbction purposes. • -- - ' • TQTAL FEE EVERSE.FOR EXPLANATORY LANGUAGE I ' Signature of Permittee Date i