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Home My Public Portal About5825 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE B75(11-84) MISCELLANEOUS APPLICATION I hereby afcert that If have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, of a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.Q. BUILDING Policy No. Company FOR APPLICANT TO FILL IN ADDRESS ILD Certified copy is hereby furnished. DDOR NG 82 �� LOCALITY ElCertified copy is filed with the county building inspection LOCALIESS 2�TY NEAREST department. , CROSS ST. Date Applicant NEARESTDISTRICT NO. GF�UP TYPE P ESSED BY CROSS ST. A (I -�( CONST. 7/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (/e [J COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL INO. OF NO. (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT SLOGS. USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) us9 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 so as to become subject to the Workers' Compensation Laws. 6 OCCUPANCY GROUP ADDRESS S9ZS 1 Ez�] O Date Applicant LU TEL NOTICE TO APPLICANT: If, after making this Certificate of CITY - No.X Rik 4-11-644- OCCUPANT LOAD N Exemption, you should become subject to the Workers' APP ICATION FOR EXIT HARDWARE: z 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 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 amp nd- �AeSS', PARKING effect. r�, _ SPACES RVQ PROVIDED License Number Lic. Class CRLAC b't A " LIMITED TIME USE Contractor Date OATO OATH FROM: TOC I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF SIGNATURE I INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDINGAlai Lic.or Reg.No. DateIN I _ V Q � HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE 00 I hereby affirm that I am exempt from the Contractor's 1,�' COCO-13001 5f 7/5 7 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING ,�„f� qr.I 1 Pri 3g3 "'1 I, as owner of the property, will do the work and the SPACES PROVIDED J.L structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY rPROPOSED USE OF BUILDING 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.Q. � Lender's Name PROPOSED MAX. OCC. Lender's Address ��IIy�� PERMIT FEE 5 vV I 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, and hereby authorize representativ of this County to enter TOTAL FEE Igg-6 V-D upon the ab -mentionedroprp e er or inspection purposes. ` S_ n SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Ptee to 7 f' I WORKERS'COMPENSATION DECLARATION zo--ooe DPwl2i90 MISCELLANEOWS APPLICATION J� I r'� I hereby'affirm that I have a certificate of consent to self COUNTY OF LOS""•ANGELES I � �BUILDING AND SAFETY DIVISION IIu'I ►insure,or a certificate of.Wor7ters'Compensation Insurance or a certified copy thereof(Ser:.3800, Lab.Q-" - _ I (� I Policy No. Company FOR APPLICANT TO FILL IN BUILDING A BUILDING ADDRESS ADDRESS ❑ Certified copy.is hereby:furnished. g Z 0Sr_—ME!Ab DLLOCALITY t I ❑ Certified copy is filed with the county building inspection CITY ZIP ,y ,7�® °'� NEAREST I department. �'T CROSS ST. Date Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT( NO. MAP HIGHWAY 1 I COMPENSATION INSURANCE • NO. ICInCLel 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 ($100) or less.) ' ti 1 ( 1 I I.certify that in the performance.of the work for which this Law 4, Assoeng-mslast-565- permit TELNo: 6r i permit is issued;I shall not employ any person in any manner t I so as to become subject to the Workers' Compensation Laws. ADDRESS � �� COa6Vj)Y 5'rRece-r 43� OCCUPANCY GROUP ( I Date Applicant . CITYZIP ?z 1 I I NOTICE TO APPLICANT: If; after making this Certificate OCCUPANT LOAD of Exemption• you should become subject to the Workers' APPLICATION FOR Compensation provisions of the-Labor Code,you must forthwith EXIT HARDWARE: comply with such provisions or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ t ' revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION C$ Panic Devices ❑ I hereby affirm that I am licensed under provisions Of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) NO.OF EXITS a r I 9(commencing with Section 7000)of Division 3 of the Business ame o us ess and Professions Code,and my license is in full force and effect. 11` PARKING• REWD D PROVIDED D g � License Number LimClass M�f�AL C-55-ROW SPACES ( I I Contractor Date LIMITED TIME USE ! ❑ I am exempt from the licensing requirements as I am a DATE DATE licensed architect or a registered professional engineer FROM: To: acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S and Professions Code). EXISTING BLDG. STORIES p� SIGNATURE. Lim or Reg.No. Date PRESENT USE OF BUILDING FINAL APPROVAL ' HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS O ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ( 1 PIofessions Code): NO.PARKING SPACES PROVIDED i ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale(Section 7044,2 PROPOSED USE OF BUILDING Business and Professions Code). 179AL 657-A-46 C6CR0Q W66 i CONSTRUCTION LENDING AGENCY i I hereby affirm that there is a construction lending agency for 1 the performance of the work for which this permit is issued ( I (Sec. 3097,Civ.C.). PROPOSED MAX.OCG i Lender's Name APPLICANT IffiW) e 20b Lender's Address ADDRESS0 I i I certify that I have read this application and state that the meq® B, mc On, wl above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE ;r the above-mentioned property for inspection purposes i I '• ' TOTAL FEE g 6/OZ SEE REVERSE FOR EXPLANATORY LANGUAGE' j Signature of mittee Date