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Home My Public Portal About5803 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 C I hereby a'fcertithat I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,,e,or a certified copy thereof(Sec.3800,Lab.C.). Policy Nf . Company FOR APPLICANT TO FILL IN BU.I I:D'I NGC (! ADDRESS Q Certified copy is hereby furnished. �` gDDRES. 5-g#3 RoSG/�lE/�D a ✓ r1T�1PLE LOCALITY ElCertified copy is filed with the county building inspection LOCALITY C4 TY NEAREST department. _ CROSS ST. Date Applicant NEAREST '� pp /y y� DISTRICT NO. GROUP=1YOP.M., P CESSED BY CROSS ST. 1,A5 Tl'i /J& , I Y/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OR HLDGS. (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. a 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 (II.I- M4A] 9MpV y so as to become subject to the Workers' Compensation Laws. MAIL ' OCCUPANCY GROUP o ADDRESS 7-06 oe6r(c4plTE 12�>; 60K .i � Date Applicant TEL. u l OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY LoN(J Qjf-G No. 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 ❑ � E [:] ❑ No Spec. Knowl. deemed revoked. .LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION C] Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT [J (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi 1 NO. OF EXITS ness and Professions Code,and my license is in full force and effect. x LIUM, PARKING RHO'D PROVIDED SPACES 11�� License Number Lie. Class TcLG M GI hh�1A R- pmjm LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF FROM: TO: IN IGN TORE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). 1✓�A FINAL APPROVAL Lie.or Reg.'No. . ' Date PRESENT USE OR BUILDING ' HOME OWNER-BUILDER•DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE �}I �„.n — � EE I her 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 '_l� I, as owner of the property, will do the work and the `x;19 structure is not intended or offered for sale (Section 70.44,Business and Professions Code). i z =; ZX- CONSTRUCTION LES DING AGENCY PROPOSED USE OF BUILDING' I hereby affirm that there is avDconstruction leading agency 1 for the performance of the work for which this permit is i ! 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 MAT 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 i TOTAL FEE , upo the abo e-mentio ed property for inspection plarpyes. SEE REVERSE FOR EXPLANATORY LANGUAGE I S' ature of Permittee Elate I 1\'oR1:L'RS'COMPENSATION DECLARATION E 875 111.841 a ICMISCELLANEOUS APPLICATION ICE 87 I hereby affirm that I have a certificate of consent to selfCOUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ' 1 insure, or a certificate of Workers'Compensation Insurance.or :t-.ertified copy thereof ISec.3800.Lab.C.). `y Policy No.--Company FOR APPLICANT TO FILL IN BUILDING ADDRESS �i- Certified copy is hereby-furnished. BUILDING J/ � f AD OR ESS ��a3 /!/. ��.SGi•�LYO' /RE LOCALITY L/ I + Certified copy is filed with the county building inspection LOCALITY Temple City CROSS ST. Date Applicant NEAREST / OISTR CT NO. GROUP TYPE �p ESSED BY CROSS ST. /,O r "Vwa s �/ ON CERTIFICATE OF EXEMPTION FRO>I'YORKERS' LEGAL o I COMPENSATION INSURANCE ' DESCRIPTION LOT NO. (BLOCK (.AAP HIGHWAY STATE MAJOR SECOND LOCAL I NO. OF SLOGS. No. (CIRCLET (This section need not Ile completed if the work involved TRAc- NOW oN LOT USE ?ONE SPECIAL CONDITIONS by the permit is for one hundred dollar, (S1001 or less.) use OF j a SIZE OF LOTI EXISTING BLDG. I certify that in the performance of lie wont- for which -his = permit is issued. I shall net employ-any ne:son :n any manner O WNER C � 'p Q �//!J .971�ll �'V 'f s,r�- so as to become subject to the Workers' Compensation Lasts. OCCUPANCY GROUPMAIL I� — ADDRESS I Date Applicant �J NOTICE TO APPLICANT: If,atrer making ::lis Cert-irate nt $I crrY, i! ✓�? O C� �//�yam`l6/9)-S6✓��3.�3 OCCUP4N-LOAD Exemption. you ,Mould become subject :o the —ITkers 4PDLICA ICNcOF =X IT HARDWARE Compensation provisions of dhe Labor::ode, you must forth- with Collin)) with inch ilrol•Won, or '111, "ermit illall Ile -RAILER USE El GEOLOGY INSPECTION _ NO SDeC. Krlo:Vl. Ej ? deemed ranked. LICENSED CONTRACTORS DECLARATION' OCCUPANCY INSPECTION$$ PanjcDevires I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT I--. (LIST ITEMS BELOW) 9 (commencing with Section -000) of Division 3 JI the Busi- L"' NO. OF EXITS ness and Prnfessiuns Code,and my- license is in foil force and j effect. PARKING SPACES REO•D I I PROVIDED a i o License Number Lic. Class LIMITED TIME USE LL /� y Contractor Date OATH OATH W F'R7M: TO: H EJ I am exempt from the licensing requirements :is I art .I 9 ) licensed architect or a registered pTofessiona_l engineer SIZE of qq C .lo. of INSPE CTORE Z actin!_ in my professional mrazlty Se:tioil -f)51. [ills- EXISTING BLDG. J�P9.S `f STORIE3 � SIGNATURE a iness.andPmfe,sicnsCade1. FINAL APPROVAL C PRESENT USE OF BUILDING Lic.or Reg. No. — Date 11 2� 5 I HOME Off NFR-13UILDER DECLARATION NO. OF EXISTING BUILDINGS d`+-�E ON LOT AND USE I hereby affirm that I am exempt from the Contractors I License Lala for the followin- reason (Section 71131.:. Busi- ness and Professions Code): NO. PARKING J El1, as owner of the property. will do the work and the Braces PROVIDED qV/ structure is not intended or offered for sale (Section I 7043.liusincis and Professions Code). !' X CONSTRUCTION LENDINGAGENCY i PROPOSED USE OF BUILDING 1 hereby affirm that there is a construction lending agency ,Iwy sl e�yjjC pe 1 for the performance of the work for which this rmit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's.address 3 I certify that I have read this application and state that the PERMIT FEE 25.00 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 I upon the Ove m htio perry for inspection urp es. SEE REVERSE FOR EXPLANATORY LANGUAGE a Signature of Permittee Da