The URL can be used to link to this page

Home My Public Portal About5823 ROSEMEAD BLVD_Miscellaneous__ ' , WORKERS'C,'UMY>;lv�}ltvty unc.t.,�xxtivty - 20-0063DPwt zieo IYi.1 t,•C L)L.H 11i 1G V�.d a H i"'Jr L,l�..rs a •a�✓x t ,I hereby*affirm that I have•a certificate of consent to self COUNTY OF LOS ANGELES BUILDING•AND SAFE'T'Y DIVISION vrihsurc,or a certificate of.Wbrkcen'Compensation Insurance,or i i a Certified copy thereof(Sed. 3800,Lab,C.)r ! Policy•No. Company FOR APPLICANT TO FILL IN BUILDING • ('"� - ADDRESS •'•! LQ•J Certified coPY,is hereby;furnished. BUILDING ADDRESS ' Lcr�Lmr Certified copy is filed with the county building inspectia Ct�F� �� ZIP ��!! NEAREST - ' + department t p Applicant V cR°ss ST. Date '� �' s SIZE O LOTr NO.OF BCDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CEM FICATE OF EXEMPTION FROM WORKERS' CONST. O COMPENSATION INSURANCE TRACT B15 LOCK LOT No. •,np ++Ia+wwY 0 ('Phis section need not be completed if the work involved No. (CIRCL6) STATE MAJOR SECOND LOCAL.. by the permit is for one hundred dollars ($100) or less.) ASSESSOR MAF BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS L certify'that in. the performance.of the work for whichth s '�&r er T;` No. permit is issued;I shall not emplby any person in any mann r I so as to'become subject to the Workers' Compensation La ADDRESS Convoy � J� � .3m OCCUPANCY GROUP � Z Date Applicant . CITY ZIP NOTICE TO APPLICANT: If; after making this Certificate 10 Die O Of A I11111 OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR Compensation provisions of ihe-Labor Code,you must forthwith EXIT HARDWARE: comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ ` revoked No Spec.Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Cg Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter- SAFETY PERMIT❑ (LIST ITEMS BELOW) - i 9(commencing with Section 7000)of Division 3 of the Busine lI'31IIeSS NO.OF EXITS Mme and Professions Code,and my license is in full force and effec S License Number Lit"Class VCDr WOffitil PARKING•SPACES REO'D PROVIDED ( ttt�.��J�JJJ 1 ( Contractor Date LIMITED TIME USE + DATE . I ❑ I am exempt from the licensing requirements as I am a - - DATE 1 licensed.architect or a registered professional engineer FROM: TO: ! acting in my professional capacity(Section 7051,BusinessslzE of ` No•DF INSPECTOR'S - and Professions Code). EXISTING BLDG. STORIIEs SIGNATURE. Lia or Reg.Na - Date PRESENT use of BUILDING FINAL APPROVAL 1 HOME OWNER-BUILDER DECLARATION NO. OF SND USEBUILDlNGS ONLOT I hereby affirm that I am'exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code); NO.PARKING .SPACES PROVIDED ' i I, as owner of the property, will do the work and t structure is not intended or offered for sale(Section 704 PROPOSED USE OF BUILDING Business and Professions Code). i 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 30$7,Civ.C.). PROPOSED MAX.OCC Lender's Name APPLICANT rMNT) l ruN. Z Lender's Address ADDRESS j I certify that I have read this-application and state that the 1414 ' ) MorelUS above infonmation.is correct I agree to comply with all County PERMIT FEE r ordinances and State laws relating to building construction,and - J hereby authorize representatives.of this County to enter upon ISSUANCE FEE 1:`=t the above-mentioned property for inspection purposes. - t j• r' S TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE- • Signature of Permittee Dat I - WORKERS'COMPENSATION DECLARATION CE 875 �1 1.84) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that 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 a certified copy thereof)Sec.3800.Lab.C.). _ Policy No.17ompany nR v�AIiIS FJh(0 FOR APPLICANT TO FILL IN BUILDING (!� -3 7 ADDRESS Certified copy is hereby furnished. BUILDINGLOCALITY ADDRESS 1 Certified copy is tiled with the co n uildine inspection NEAREST depa LOCALITY ent. Temple•City CROSS ST. 101, Date —Applicant NEAREST (� DISTR DT Nqw GP TYPE P SSED BY • CROSS ST. U}S V�y.'rIS Ot/ CONS I CERTIFICATE OF EXEMPTION FROM•.LORKEW LEGAL ' COMPENSATION INSURANCE • DESCRIPTION LOT NO. !BLOCK (MAV HIGHWAY ^IO. (CIRCLE) STATE MAJOR SECOND LOCAL I NO. OF BLDGS. (This section need not he completed if the work Involved TRACT NOW ON LOT USE ?ONE SPECIAL CONDITIONS by the permit is for one hundred dollars iS100) or less.) USE OF i ) • �SIZE OF LOT EXISTING BLDG. I certify that in the Performance of :lie work :or which -Itis permit is issued. I shall not employ any ?e-.son in any mannerOWNER�_ I AC�6[_N` ,T 5 '^ - so as to become subject to the Workers* Compensation Laws. �,SAIL �J r 1{ OCCUPANCY GROUP Date Applicant Illi �`j� IJJI AD DR ESS '�O°I ♦r�'rA iaT S-1 �F�DU I •• NOTICE TO APPLICANT: if. after making ::tis Certificate pit $I cITYsPf4 p�E60 • vo` ' 61 _b(� —3 OCCUPAN' LOAD Exemption. you .Mould become iubiect :o the �\orkers•' APDLICA-1CN COF =X IT HARM-11ARE Compensation provisions of the Labor Cade. you must forth- ) with COmDil. with iuch nrovisions or :his -•ermit shall be -RAILER USE1:1 GEOLOGY INSPECTION NO Spec. KnoNI. deemed:e%oked. LICENSED CONTRACTORS DECLARATION ' OCCUPANCY INSPECTION$$ Panic Devices 'I I iterebv affirm that I am licensed under provisions of Chapter SAFETY PERMIT � (LIST ITEMS BELOW) ► 9 1commencine with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Prufcssionq Code.,Ind my license is in full t'ori:e and effect. PARKING SP4 CE5 REDO PROVIDED �, I a License Number Lic. Class o + LIMITED TIME USE LL /• N Contractor Date— TATE DATE ZP,7M: TO: 0 1 am exempt from the licensing requirements as 1 am a a ) licensed architect or a registered professional engineer SIZE OF VO. OF INS PR's O !�- EXISTING BLDG. STORIES SIG A URE z actin-and P:ofessicnsCade l• FINAL APPROVAL O PRESENT USE OF BUILDING U Lic.or Ree.No. Date— 1 _ ,lr!—(�-p-- HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS Ol� IJiJ� '�- .,21//9 ON LOT AND USE i p '1 L•I s� L [ hereby affirm that I am exempt from the Contractor's �II ��Iryr L I'ii:I t I License Law for the following reason (Section 7031.=. Busi- ness and Professions Code): NO. PARKING D1, as owner of the property. will do the work and the SPACES PROVIDED structure is not intended or offered for ,:Ile iSection I 704.1.Business and Professions Code). X PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affinn that there is a construction lending;:igency My UMM I for the performance of the work for which this permit is issued(Sec. 3097•Civ.C.). v WN DseS Lender's Name _ PROPOSED MAX. OCC. Lender's.address I PERMIT FEE 25.00 I certify that I have read this application and state that the above information is • .I agree to comply with all County ISSUANCE FEE ordinances and ate s relating to building construction. and hereby auth ' representatives of this County to enter TOTAL FEE 25.00 1 upon the a�bovceftti roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE tgnature of Permittee Date