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Home My Public Portal About5805 ROSEMEAD BLVD_Miscellaneous__ e ( � WORKERS'COMPENSATION DECLARATION 1761,1A44 IVII C I..i_r;N U A P PL I C AT I O N ! hereby affirm that I have a certificate of consCE 875(11.84) .7ent to Leif COUNTY OF LOS ANGELES tUILDING AND SAFETY DIVISION • insure, or a certificate of Workers'Compensation Insurance. L—i a certified copy thereof(Sec.3800.Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDINGJZA-1 ADDRESS a(/r./ 1 ' ❑ Certified copy is hereby furnished. BUILDING ) XX 1 ADORES S D LOCALITY Certified copy is tiled with the county building inspection I LOCALITY .�`A �o� NAR EST department. XXI �lYt Viz CH OSS ST. Date Applicant NEAREST D.IS'TR ICT NO. GRgyUP TYPE ESSED BY CROSS ST. , D O /�( CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a moi/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK 04,rp HIGHWAY STATE MAJOR SECOND LOCAL NO. OF SLOGS. NG. (CIRCLE) (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 (SI00) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this — c permit is issued. I shall not employ any person in any manneXX OWNER of building _ so as to become subject to the Work-ere Compensation Laws. ML OCCUPANCY GROUP c c ADAIDRESS LV L Date Applicant NOTICE TO APPLICANT: If.after snaking this Certificate of CITY NOL OCCUPANT LOAD Exemption. you should become subject to the Workers' I 11App Ll TION FON EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth with comply with such provisions oI this permit shall be i TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION it OCCUPANCY INSPECTION ❑ _ Panic Devices I Hereby affirm that I ;m licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencil>? tvuh Section 7000) of Division 3 of the Busi- No. of Exirs nese and Professions Code.and In.1 license is in full force anix Name of business PARKING � effect. I SPA CES REQ'D PROVIDED L..� ��u�r�e ( License Number Lic. Class + LIMITED TIME USE �! I Contractor Date __ DATE DATE TO: 7 I am exempt from the licensing requirements as I .Im :I licensed architect or a registered profLssional engineer 612E OF No. of INSPECTOR'S I i i c- XISTING BLDG. STORIES SI ATURE acting in nt)' professional capacity (Senion 70.1. B,i, iness and Professions Code). �PRESENT USE OF BUILDING IFjNAL APPROVAL -6 Lic.or Ree.No. Date (� 6` ^' ruHOME OWNER-BUILDER DECLARATION � NO. OF EXISTING BUILDINGS //�� 6&0-171•--�—li� � ON LOT AND USE U '�� al40 ' -`t-i Z`{•! 14 I hereby affirm that I am exempt from the Contractor's (� /V/' 2,74 I F'i; [isfl License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): (1I NO. PARKING i I. as owner of the property, will do the workand the r SPACES PROVIDED structure is not intended or offered for sale (Section I 7044.Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 4 I Hereby affirm that there is a construction lending agency I iI for the performance of the work for which this permit is 1 issued(Sec.3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address � PERMIT FEE 00 I` I certify that I have read this application and state that tlie 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 1 upon the above- ioned property for inspection purposes. i SEE REVERSE FOR EXPLANATORY LANGUAGE XX A, XX ` I Signature 'ttee ate I 11'OI21;L'RS'('OMP[:NSATION DL'('L.11ZA1'lON 8c CE �� aaI MISCELLANEOUS APPLICATION cs a I herebyaffirmthat 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 t a certified copy thereof iSec.3800.Lab.C.). Policy No. -l,iilivan\' !DURESS Nc �JD� FOR APPLICANT TO FILL IN ADDRESS rf/ Certified copy is hereby furnished. X BUILDING `� 5 c� ADDRESS J 0 /b 1 RG5R, L]CALITY I Certified copy is filed with the county building inspection LOCALITY NEAREST department. Temple City CROSS ST. or Date—Applicant NEAREST � DISTRI T NQS GR P TVP CESSED BY CROSS ST. 2DZjC GV,elJ�c! /y y CONS CERi1FICATE OF EXEMPTION FROM�•1ORKERS• LEGAL (�OOO I COMPEM.MON INSI'R.\NCE DESCRIPTION LOT NO. !BLOCK I MAI .IIGNWAY NG. (CIRCLICI STATE MAJOR SECOND LOCAL NO. OF BLDGS. (TMs section heed not lie comoleted If the iiork involved 1-RACT NOW ON LOT USE :ONE SPECIAL CONDITIONS by the permit is for (me hundred dollars +511101 or less.) ? USE OR ( I SIZE OF LOT EXISTING BLDG. I certify' that in :lie performance of :lie work for'i•hich -hisituptiza. ---;__ permit is issued. 1 dial) not employ any 7e-son many manner OWNER 1 �GA/so as to become itlbiect :o the `t'orkets' I nmensation Laws. MAIL z OCCUPANCY GROUP - ADDRESS / ` �SGG _ I Date -►pplicanr p -_ NOTICE TO APPLICANT: If.:af:cr makirs :!lis I . :[irate :,t $j CI.'44 �GG vo� �)Z 2��38 OCCUP4N-L^..1% Exemption. you should become itiviect -o he 111-kers' a DL!CA'IC�! ��F =X'-44RC1i?�pc Compens:Itlon provisions of-he Labor Coda. you must north- � / - ! with cotn:iiy -1111 .ueh provision,; or hi. '•ermu ;hail be n 1 f i -RAILER :l^sE GEOLOGY :NcPE,=TION —' I`lO SDeC. :1CtvI. deemed:cioi:r,i. - - LIST ITEMS 3ELO V/l OCCUPANCY INSPECTION$$ Panic Devices ❑ LICENSED CONTRACTORS DECLARATION _ 1 hereby :affirm :(rat 1 am licensed Under preeislons o,Chapter 9 1conilliencine with Section 7000) of Di,inion ? } WORKERS"COMPENSATION DECLARATION 7snn444 MISCELLANEOUS A P P L i C A T i�N I Hereby affirm that I have a certiete of consent to self CE 875(11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 'd insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.Q. a �j Policy No. Company FOR APPLICANT TO FILL IN BUILDING DRESJr�J D, r ; a Certified copy is hereby furnished. UtLDtNG ' DDRESS • �� . O _ f a J 40 CA LITY' } Certified copy is filed with the county building inspection'.- LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST (k V 4 DISTRIC INOy GROUP TYPE �.��F P ESSED BY CROSS ST. S ilLr V `�S J}(/ CONST.'[/ ! CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL jf(I COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NISHWAY NO. OF SLOGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed If the work Involved TRACT NOW ON LOT rSEZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (S100) or less.) USE OF I IZE . OF LOT EXISTING BLDG I certify that in the performance of the work for which this _ permit is issued,I shall not employ any person in any manner ER 57. 0 C;�qv. �k (_ So as to become subject to the}Yorkers'Compensation Laws. MAIL 3O§Q 1Yv�aeL OCCUPANCY GROUP I Date Applicant ADDRESS NOTICE TO APPLICANT: If,after making this Certificate of CITY C7,--CNOL 76 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' Y GEOLOGINSPECTION 14 deemed revoked. ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices Q °' I hereby affirm that I am licensed under provisions of Chapter } 9 (commencing with Section 7000) of Division 3 of the Busi FETY PERMIT❑ (LIS EM$ BELOW NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING REq'D I I PROVIDED I I m SPACES M ) License Number Lic. Class LIMITED TIME USE LL W Contractor Date DATE GATE I am exempt from the licensing requirements as I am a FROM: TO` I licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S Z acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI TURE Um iness and Professions Code). FINAL APPROVAL /f PRESENT USE OF BU3LDING G Lic.or Reg.No. Date cc 1 �y HOME OIVNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS — � / `3.j7-0 ON LOT AND USE 9?7- 9 I hereby affirm that I am exempt from the Contractor's �' f I•.I.� j• AI'i {s.Ie 0• } ! License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 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). CONSTRUCTION LENDING AGENCY ROPOSfiD VSE OF BUILDING I hereby affirm that there is a construction lending agency } for the performance of the work for which this permit is issued(Sea 3097,Civ.Q. Lender's Name Lender's Address PROPOSED MAX. OCG. } 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, 1 and hereby authorize representatives of this County to enter TOTAL.FEE 25.00 _upon the above- entioned property for inspection purposes. 4 SEE REVERSE FOR EXPLANATORY LANGUAGE l S(enat ittee \ Date y WORKERS'COMPENSATION DECLARATION CE 875(71-84) MISCELLANEOUS APPLICATION CE e76 1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, ora certificate of Workers Compensation Insurance,or 'a certified copy thereof(Sec.3800,Lab.Q. ' Policy No. Company FOR APPLICANT TO FILL IN BADUILDINDRESS vx R G � aLS2 (3IVd Certified copy is hereby furnished. X fx ADDRess t7g0.� R 0�M120.1Q ka . LOCALITY "_,eW,pJe C,f Certified copy is filed with the county building inspectio�I LOCALITY RVv� g Cif NEAREST (_A5 LLv�o�S fid' department. ]CX, pl T CROSS 9T. T Date Applicant NEAREST r o S AM Nas DJ'• DIST oNO. UP ITYPE CONS OCESSBD BY CROSS ST. L•v` Op CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO.OF BLDGS. (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. I certify that in the performance of the work for which this J permit is issued,I shall not employ any person in any man le g-,OWNER Of buildin efGAC so as to become subject to the Workers' Compensation Laws.— MAIL `�Yn 1� OCCUPANCY GROUP o :J ADDRESS �LVy C~.� Date Applicant I TEL• OCCUPANT LOAD n- NOTICE TO APPLICANT: If,after making this Certificate of CITY lem CI 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❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices 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 Busi- NO.OF EXITS ness and Professions Code,and my license is in full force effect. 'Name of business PARKING 11 REQ,D 1 I PROVIDED SPACES J License Number Lic. Class 0VOLET CRE& T1J C LIMITED TIME USE Contractor Date DATE DATE F RC M: F1 I am exempt from the licensing requirements as I am a licensed architect or a registered profbssional engineer SIZE of No.of INSPECTOR SIGNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). FINAL APPROVAL Lic.or Reg.No. Date PRESENT USE OR BUILDING HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS 19 /6 f ON LOT AND USE I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO.PARKING 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). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency .,I Q For the performance of the work for which this permit is issued(Sec.3097,Civ.Q. L' ISI Lender's Name CI PROPOSED MAX.OCC. � + ' Lender's Address 1 certify that I have read this application and state that the PERMIT FEE above information is correct.I agree to comply with a5.00 ll County ISSUANCE FEE 13 ordinances and State laws relating to building construction, . and hereby authorize representatives of this County to enter TOTAL FEE 2rj.00 – .Q upon the abo � n io ted perty for inspection pur oses. C :.r i f � 617_ /SEE REVERSE FOR EXPLANATORY LANGUAGE , XX c:....., ...,, U......: ..,, Date