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Home My Public Portal About5817 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION a r CE CE B75(11-84) M 15C E L LA N EO U S APPLICATION {� � 87Ll 11affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insureure,, o or a certificate of Workers'Compensation Insurance, e,or a certifd copy thereof(Sec.3800,Lab.C.). Policy l o.�__ - 'ompany S�1N Ins araAnce FOR APPLICANT TO FILL IN BUILDING;O/7 S� 1.0 C ADDRESS a Certified copy is hereby furnished. ADDRESS �D 0$Q �j�v LOCALITY ElCertified copy is filed with the county building inspection LOCALITY �'� `e NEAREST department. r�/�/� �/� CROSS ST. Date Applicant_L�-Wa ou r NEAREST DISTRICT NO. GROUP IT YPE P CESSED BY CROSS ST. .0-ex e P CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. OF BLD 65. NO. (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 ($100) or less.) USE OF SIZEOF 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 Ch.a rvi )o so as to become subject to the Workers' Compensation Laws. MAIL I ZIh OCCUPANCY GROUP �� ADDRESS ZD6 OcC CA • ODV O Date Applicant L"LI NOTICE TO APPLICANT: If, after making this Certificate of CITY �h NDLTrz '310—g37$0q 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. El deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (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 REq'D D PROVIDED License Number Lic. Class PCwa -e_haU� SPACES 6-00 osayv � )V LIMITED TIME USE Contractor Date D ATE DATE ❑ I am exempt from the licensing requirements as I am a 17 Q° licensed architect or a registered professional engineer SIZE OF NO. OF FROM: To. INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. Im 20 STORIES SIGNATURE iness and Professions Code). C FINAL APPROVAL 4_ PRESENT USE OR BUILDING L Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS V /1� _1 i" � _ 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 usi v 905j_�-- 7;' �ri 7 i ness and Professions Code): NO. PARKING - - ❑ I, as owner of the property, will do the work and the SPACES PROVIDED �V__ _ P;1 2a49 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 CPM U,4-cr• re-Miter for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name PROPOSED MAX. OCG. Lender's Address I certify that I have read this application and state that the PERMIT FEE above information is rrect.I agree to comply with all County ISSUANCE FEE ordinances an ate la relating to building construction, and by thorize rep sentatives of this County to enter' TOTAL.FEE u nth a ve-mention roperty ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE AJA Sign of Oerrnittee D ee WORKERS"COMPENSATION DECLARATION 76M444 CE 875 17.84) MISCELLANEOUS APPLICATION I hereby'affirm that I have a certificate of consent to self i `I 1 insure. or a certificate of Workers'Compensation Insurance.or I COUNTY OF LOS .ANGELES BUILDING .AND SAFETY DIVISION ;y; a certified copy thereof'Sec.3800.Lab.C.i. - Policy No. _lantpan) FOR APPLICANT TO FILL IN ABUILDI DDRESS �7/7 Certified cop} is hereby furnished. BUILDINGa/�(+ �il n�l J LO CA LIT10*7 ADDRESS ��JOQ t tiCJ(J I/ /j V I ! F� Certified copy is filed with the county buildinc inspection i LOCALITY department. Temple City NEAREST CROSS ST. Date Applicant NEAREST DISTRI N GR P TYPE OC ESSED BY , m CONST C I CERTIFICATE Of EXEMPTION FR0�1'•�ORI:ERS' LEGCROSS ST.AL COMPENSATION INSURANCE I DESCRIPTION TOT NO. IBLOCK MAP HIGHWAY 1 MA (CIRC LEI STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved NO. OF GLOGS. P -RAC- NOW ON LOT USE TONE SPECIAL CONDITIONS by the permit is for one hundred dollars (S100) or less.) USE OF 1 I certify that in the Performance of .he%vor4 fu:which -Itis slzE of LD EXISTING BLDG. permit is issued. I shall not employ an% '+e:son :n any manner OWNER S. L�I1/ SSQ G1,NrES __A)L_ , so as to become subject to the Workers*.C.mivensation Laws' MAIL /�� OCCUPANCY GROUP ADDRESS Date Applicant 3709 CJOA1VaY$T lSu/tEVo a I• I -EL. Iq SGS 8�� OCCUP4N-LOAD NOTICE TO APPLICANT: If,af:e:makim: :his Ccrti is:lie +t cIT N DJE(T- Q moo. Exemption. you ihould become iubject :e -he Workers' lumpensation provisions of the Labor a .�da, you :Host forth 4P°L!CATIC'� c�F 7�(IT 4nRD%%?ARE with comply with welt proviMonl or 'Ills -er-nit ilial! be -RAILER USE GEOLOGY :NAPE CTIONn 1 1 deemed:e+oked. — No Spec. Krlowl.Panic Devices ❑ LICENSED CONTRACTORS DECLARATIONOCCUPANCY INSPECTION$$ � I hereby affirm that I am licensed under Provisions of Cllavter SAFETY PERMITt^_, (LIST ITEMS BELOW) 9 (commencing with Section 70001 of Division 3 of the 13usi- NO. OF EXITS ness and P:nt'essions Code,and my license is in :till force and effect. PARKING REO'O O PROVIDED D SPCCES License Number Lic. Clas< LL LIMITED TIME USE a Contractor Date ,ATE DATE W IZ-n ❑ I am exempt from the licensing requirements as I am .1 r°' 'm I licensed architect or a registered professional engineer ilzE of . of I INSPECTOR' Z acting in •71t• professional CSill)n:ll :ar'I::li:• Se::10:1 It;I. Bll i- EXISTING. NoO BLDG. STR165 S Iq AT1.UR iness anti Professicns(ode I. 'N A L APPROVAL O c Lic.or Rea.No. Date "RESENT USE OF BUILDING I �► U 1 IP--.LL HOME OWNFR-BUILDER DECLAR.kriON NO. OF EXISTING BUILDINGS f J srL ON LOT AND USE p 6408 � PM �� +, 1 hereby affirm that I am exempt from the Contractor's I License Law for the following reason 'Section -031.5. Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED 1, as owner of the property• will du the work and the structure is not intended or offered for :ale 'Section I 7044.Business and Professions Code). CONSTRUCTION LENDING AGENCY g PROPOSED USE OF BUILDING I� 1 hereby affirm that there is a construction lending ;Tencv WAIL SToRZ sIELL, L*1t,) 1 for the performance of the work for which this permit is issued ISee. 3097,Civ.C.). Q1 ,4 ,t Wooj Lender's Name _ Lender's Address I FU7 1714 PCC- PROPOSED MAX. OCC. I I certify that 1 have read this application and State that tile' PERMIT FEE 25.00 } above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to buildirt construction, ai►d hereby authorize representatives of this County to enter TOTAL FEE 25.00 ' 1 upon the above-menti d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i o..ZS I Sof Permittee Date • .1 ..0 6/0 I I•O IT71wJV1—ILl-1I 'lL_'.J '-•Iv i %J 1 Ll%—#7 A 1 Ivl -+ I hereby affirm that I have a certificate of consent to ielt' I l 0UN lY OF LOS .�vG£L�S Bi;ILDING .AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance.Jr L : a certified copy thereof(Sec. 3300.Lab.C.). I S P Y f FOP. .aPPLICAVT-i��IL' 'I ; : SBUILDING Poucy No.—Company j _ 1 AD R : 1:1Certified copy is hereby furnished. X I BUILDING 7 R6 IVie4b .moi e_ j1 e i AO DRESS '-F I-OCA LITY Certified copy is filed:vitic the county buildine inspection t-770 'NEAREST LOCALITY department. '. _ �I=ROSS ST. Date Applicant NEAREST �� li 71STRIC V . � G P TYPE CESSED BY I CROSS ST. L ccN CERTIFICATE OF E.YENIPTION, FROM WORKERS' LEGAL ( ] COMPENSATION INSI 'SURA. 7EGCRIPTION LO NO. LOCK CK j'nA. .IIGMwnY STATE MAJOR SECOND LOCAL VO. OF SLOGS. (This section need not be completed if the work involved TRACT ;NOW ON LOT U S£ ZONE]SPECIAL CONDITIONS i by the permit is for one hundred dollars (5100) or less.) usE DF L.G.I SIZE OF LOT (EYIST:::G 3 I certify that in the performance of the work for which this � r permit is issued. I shall not employ any person in any mannek DINNER OL building s- ol I�SSOC/�i�6S /W. so as to become subiect to the Workers' Compensation Laws. MAIL �/ / /� �J� CCCUPAiNCY GROUP ` ADDRESS�7�$ C01vJe 7 -g.-W-e 7v� i Date Applicant NOTICE TO APPLICANT: If, after makinz this Certificate of ` CITY(�'�jl/�l��p ( QZII vo b'sa-S( W33 i OCCUPAiV LEAD Exemption, you should become subject to the +•%'orke:s I I D_ _jR Compensation provisions of the Labor Code.you must fosh_ L P CA ' '' _i °X,T��RDtPIAR=: with comply with such provisions or :his pe:mir :hail ;:e !_4 1L_R USE —_ GEDL G' NSPe=T:c:: = No Spec. iCnouvl. deemed revoked. j LICE\SED CONTRACTORS DECL.�RATIC`; I. OCCUPANCY :N=?E.T10V °Jric Devices j I herebv affirm that I am licensed under provisions o:+;::ac!e j 9 (commencing tvit]i Section 7000) of Division = 3ti;i- , 1 SAF`T- 'ERMIT -•ST -='•1s 3E_O:':: ; VO. OF EXITS I ness and Professions Code,and my ense :s i.. ':1:1 ` ! I effect. "�:{ iName of business IPAR`INc RE.•c ' � I PRc'fID£O !� License Number— Liz. C!:s - � AfJlia C e Gj kU;s_Ly -- TPA, � _- i 1t S� � MI 1 H I lM USE Contractor Date _--_---l ' } DATE u [ am exempt from the licensing :eyucr::::-; t licensed arC111r2Ct or i e::d talc }il.•Ilal _ :: _= . :NSPECTCR's deting in my nrofessional�.apac:i}'y,S2::iu:: -'':~.'i'+t:<• -•1•_TING SL G. :-CRIE I� 51 TURE L-tessand Professions Code I. INAL APPROVALNU Lic.or Rei No. HOME ORNGR-BUILDER DELL.-k xA .t.\ VO. -- -EXISTING 3UILCING5 7:1 AND JSE � •uV 1 hereby affirm that I am exempt from rite :-or.:-sc-ar= ] it •� G 'License Law for the following reason 1 Section ne'ss and Professions Code): ' ]%0. PARKING ❑ I SPACES -ROVIOSD .' I. as owner of the pronerty. will do :lea �. -3rk arld -':I: structure is not intended or offered tar sate -1.1 J I _ 7044.Business and Professions Cede). ]` lPROPOSED L73E OF SU:LOING 1 ~� ''•' r•- CONSTRUCTION LENDING AGENCYI , t'_P1 9;-1!i I hereby affirm that there is a construction lending J.—enc':' 1.for the performance of the work far which :Itis _prm"', is' issued(Sec.3097.Civ.C.). dI Lender's Name I PROPOSED MAX. OCC. Lender's Address PERMIT FEE 25 . oOl I . I certify that I have read this application and state :hat the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances d State laws reL'iting to building construction. and hereby lionize representatives of this Couniv co :n[tr TOTAL FEE 25 .001 ; upo the ab a entioned property for inspection purposes. SEE RE`v-ERSE FOR•EXPLANATORY LANGUAGE XX XX 's I ' atu of Permittee Dace 7 WVKRCKS- LVMYCrvJHiiVIV uCL'LAKAl1UN 20-0063DPW12/90 MID�.GIL.L.HI-Ar.VUIil—rL..I%..HI IV111 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �I insure,or-a certificate of Workers'Compensation Insurance,or 1 a certified copy thereof(Sec. 3800, Lab.C.) Policy No. Company-__ FOR APPLICANT TO FILL IN BUILDING O ,f -- --' ADDRESS ® BUILDIN AD RES Certified copy is hereby furnished. 0ph/.26-f LOCALITY Certified copy is filed with the county building inspection cls L ZIP Q department. (If try t'T l CROSS sr. Date Applicant _ _ SIZE OF LOT NO. BLDGS.NOW ON LOT DISTRIC ,NOy GR TYPE cesSED BY ( Y CONSTY/ CERTIFICATE OF EXEMPTION FROM WORKERS' o COMPENSATION INSURANCE TRACT BLOCK LOT NO. � MAP HIGHWAY NO. ICIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) en 5 _ w 1 certify that in the performance of the work for which this. OWNEI erty E�j permit is issued, I shall not employ any person in any manner ADDRES q so as to become subject to the Workers' Compensation Laws.� ,� Sq- � Ot:CUPANCY GROUP A. 1:Z:1 Date Applicant eITY I I zlgl„� NOTICE TO APPLICANT: If, after making this Certificate (� OCCUPANT LOAD of Exemption, you should become subject to the Workers' AP ICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ revoked. ( ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices � I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) 9(commencing with Section 7000)of Division 3 of the Business No.of Ex(rs and Professions Code,and my license is in full force and effect. GCi PARKING License Number Llc.Class _ SPACES REQ'D PROVIDED 0411( Contractor Date WLIMITED TIME USE DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer actin in m professional capacity , !!SIZE N NO.OF INSPECTOR'S g y pfil i p ySection 7051Business ( 1 EXISTING BLDG. STORIES SIGNATURE and Professions Code). Lic.or Reg. No. Date xI PRESENT USE OF BUILDING ,t,�, FINAL APPROVAL � HOME OWNER-BUILDER DECLARATION ,NO.OF EXISTING BUILDINGS CI U 'I ON LOT AND USE ( 1� 11 hereby affirm that 1 am exempt from the Contractor's License 11 Law for the following reason (Section 7031.5, Business and 1�� Frofessions Code): NO.PARKING \ }� El I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale(Section 7044X PROPOSED USE OF BUILDING Business and Professions Code). 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 (Sea 3097,Civ.C.). PROPOSED MAX.OCC Lender's Name APPLICANT(PRIM) TEL NO. 1 Lender's Address ADDRESS I certify that I have read this application and state that the ' above information is correct. I agree to comply with all County PERMIT FEE ordinances and State law relating to building construction,and hereby auth rize repres tatives of this County to enter upon ISSUANCE FEE the above- � oo rspection purposes. TOTAL FEE X SEE REVERSE FOR EXPLANATORY LANGUAGE Signat a ermittee D,te ,.•n,I.t f,: 1 % -111 . ,1. • . t.t . +1. ' • I. II Y 1 f-.31 L•L_L_L_/R t-.6-L.+' .-•1 -_J i 1 Q Q L 6%-0 t-%C 1 V 1 'S1 • 1 I1Crel„ ilrflflll fit, I ha1•e :1 cerliheale of coil%III ►t, sell \ ex��11� OI- I OS ANCj1:I I:S Iii II_I)IN(1 AND SAFETY DIVISION insure,ora certificate of Workers'Compensation In,ur,ocr.t+r a certil'ied cop) Ihcreor(Sec. 3800. Ii).C.) I -_ Polic) No. Company FOR APPLIGAN 1 10 FILL IN _d nooRess y BUI ADDDJRESS ❑ Certified cop\ is herch) ftlrlllslictl. L- — LOCALITY (/ ❑ Certified cap) is I Iled %%Ilk the Caltllt% hlllldlllL Ill,lleLllt,11 ---CIT,' friK�� ZIP f NEAREST department. �• � � - � v _ CROSS ST. Date Applicant SIZE OF L T�O � NO,OF,�LDGS.NOW ON LOT I DISTRICT NO, GROUP TYPE PROCESSED BY / _(7/ CONST. i C•ERlll•I(•A11 ()Ir EXL'MI'll()N FRI)M WORKI RS TRACT --- BLOCK LOTNo.--- ---� y C•OIYIPENSAI•ION INSURANC 1: I NO HIGHWAY L ) NO 1CIRCLE. STATE MAJOR SECOND LOCAL (Thk Section need not lie compicied it iiie \Lark ill,llltCd ASSESSOR MAP BOOK PAGE PARCEL USE 20NE SPECIAL CONDITIONS � h) the permil i% for one hundred dollar% 1~10111 o+ lc%%.l - ; 1 CerIII•) [hal in file Lrfonnancc of Ilk' Lun'k 1161uluLll 1111, OWNER TEL NO. permit is Issued. I shall nut [lie ti) :ke person in ,111) 111 as to became suhjccl to the 1l'orker,' ( omprns:uio,l I.:ILI, A nREss 7-1010 OCCUPANCY GROUP I Dille Applicant CITY ZIP " � �- NOI1C'I: 10 APPIACAN'I: 11'. aflel making illi, I erll icalr �[ OCCUPANT LOAD - ol' I.ecmplion. )ou shnuld 11CC0111C suh,jcct III the Wllkers KPPIICATIONFOR ! -- ihARE' Compensation prmisions of the Labor Code.)ou 11111,! I+;+Ireilil EXIT HAl1Dl comph milli such pro%kitim or Illis permit ,hall hr t rnlrtl TRan nr ot-r i GE(jI,)LY INSPECTION - 4 D1n�l;E^ ECnUwI ❑ ► L.ICENSLU CUN fR:�C IUI(S IN('LAR �llE1'� - OCCUPANCY INtrPECT1ONXI Panic Devices El I hereby :Ifflrlll that I and licensed under pruL inions al (i1.Ipter SAFETY PERMIT f - tLIST ITEMS BELOW, � a 9(commencing with Section 7000)of Di%inion 3 of the Bit!ines% - _, NO.OF EXITS and Professions Code,and m% licCllxe is in Illll Iol-CC and ellcct. � Ill n,-:r Ci �_ i,C IIi!•..•�`,> ____! PARKING. I I SPACES REO'D 1� PROVIDED i License NumbLAC. L ('la„ ----- t --- LL��JJJJ LIMITED TIME USE Contractor late - _-_----+ _—_- DATE DATE ❑ I am exempt I'rom the licensing requirements a, l .un it 1 FROM: TO: licensed architect or a regi,lered prole,sional en,: neer --- - -- ' INSPECTOR'S acting in nq profcs,um:tl caparil) ISrclion 7051. Iiii-mt 's Sl2r or NO OI" 1 LATU XISIINt,Lit I:C. - ti1f1RILti -- SIGN - and PI'IIIC„ions Code I. — - ----- ---- -- —-;t - Lic. or Reg. No. Date -- oRESr NT USE OF BUILDING FINAL-APPROVAL 2[ Bl -- ---� II()kl!- OWNER-111111 DI.R IN I I.ARAIION NO or 1 XIbI INC,BUILUINC;S a� .!N.LOT AND USE I hereby affirm that 1 ant eLenlpl from the Coll u•acltn', I :• n,e I Law for the folla+Lnlg reason (Section 7031 >. lhi%me•., and Professions Code): NO PARKING ! ❑ SPACES PROVIDED - -•_- 1. as uuncr ol• IhC proper!). ++111 do the ++ork I[I, Ill: --- --- ///�/-- --------- sirucitu•c is not intended or ollcietl fiu safe(Secnor. .nl1. PROPUSCD USE OF BI)ILDINGI IA f1_ Bushmen and I'rolessions ('ode I. - —_- CONS'IRUCTION I.ENDINO Md NC) I perch) alTirm that there is a comIruclion lelltfill-L' file performance of the %%ork for LLI»ch this permit I, suet! - - - -- --” - - e (Sec. 3097,0%.C.). PROPOSED MAX.Oc . l endeCs Name APPLLICAANNTT frat.•J;I i N LT. �E I-ender's AddressA URL' ! certify that I hale read this application and stale III,!; the -� above information is •orrect. I agree to compl) %%ilh all (•-twl% "LRM;T rcE �— 1 ordinances an 'St.' laws relatingto building constrLIC !It:. and I__-- hcreb)• a1111 represet 'Bees of this Count) in enter tlpnll I ISSU.IN.-e FrL the ab,v• mitioneL ,rop 11V ,r inspection purli-ow, �•- _- `i I i TOTAL FEF �( SH RIA1 RSI- I-OR I X11L ANIMOR) I ANGIIAGE. Signature of Ilernlirtec I)al;'