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Home My Public Portal About5827 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 75M444 MISCELLANEOUS APPLICATION ,� CE 875(11-84) I lure, o a certificate 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.Q. UILDING Policy No. Company FOR APPLICANT TO FILL IN B ADDRESS a Certified copy is-liereby furnished. BUILDING AD DR ESS LOCALITY �7� —1 �. Gr� � Certified copy is filed with the county building inspection LOCALITY NEAREST department. ,� CRosS ST. Date Applicant NEAREST DISTRICT NO, G1,oUP TYPE R ESSED BY CROSS ST. � CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL C�J COMPENSATION INSURANCE DESCRIPTION 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 US��Eyyy 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 O permit is issued,I shall not employ any person in any manner OWNER c' so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUPEZ�] o ADDRESS F•" Date Applicant gnQ ' uvI NOTICE TO APPLICANT: If, after making this Certificate of CIT . � �, NOL 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 GEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. 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 effect. PARKING ACES SPACES D D PROVIDED �— I License Number Lic. Class J LIMITED TIME USE Contractor Date DATE DATE Elam exempt from the licensing requirements as I am a PROM: To: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting In my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL J/l /� Lic.or Reg.No. Date PRESENT USE OR BUILDING G//I� / .. HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �j ON LOT AND USE I hereby affirm that I am exempt from the Contractor's O Ii t License Law for the following reason (Section 7031.5, Busi- - ness and Professions Code): NO. PARKING i I I 4 a 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 for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name I PROPOSED MAX. OCC. Lender's Address I certify that I haveiread this application and state that the PERMIT FEE , above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State!laws relating to building construction, and hereby authorizel representatives of this County to enter TOTAL FEE upon the above-mentigned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 4 Signature of Permittee Date I _WORKERS'COJIPENSATION DECLARATION CE 875(t 1.84) MISCELLANEOUS APPLICATION • ICE 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 c thereo (Sec.3800.Lal(C.,) / } �- I• PolicyNoC� a Company-Mi3d fff(I( .117hh7Ai FOR APPLICANT TO FILL-IN BUILDING I ADDRESS Certified copy is hereby furnished. LOCALITY ' /- Certified copy is tiled with the county building inspection LOCALITY NEAREST department. Temple City CROSS ST. i Date Applicant NEAR ESTDISTR T NQ. GROG P TYPE-- CESSED BY i CROSS ST. D y �( CO NST�� ' CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a /� �/ I COMPENSATION INSURANCE ( DESCRIPTION LOT NO. (BLOCK (:•IAP HIGHWAY ' nC. NO. F BLDGS. (CIRCLE) STATE MAJOR SECOND LOCAL I (This section need not be completed if the Work involved 1 TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (S100) or less.) USE OF I I certify that in the performance of the -vo:k for which this slz= of LOT - EXISTING HLD G. ' permit is issued. I shall not employ any person in any manner yt OWNER- ' 1N �' ssxx �s L r^I - i so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP I I Date Applicant ADDRESS- — emd -"Blvd( 4_J NOTICE TO APPLICANT: If, after making :his Certificate Of X CITY G /7Q0-OL. I OCCUPANT LOAD Exemption, you should become subject to the Workers' _ Compensation provisions of the Labor Code,you :rust forth- V APPLICA T ION FOR EXIT HARDWARE. with comply with such provisions or rhis permit shall be l:'RAILER USE GEOLOGY INSPECTIONNo SpecEldeemed revoked. ; . Know{. LICENSED CONTRACTORS DECLARATION I OCCUPANCY INSPECTION$$ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) l 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 affect. t PARKING R.W. O PROVIDED N SPACES o s License Number Lic. Class LIMITED TIME USE n I Contractor Date DATE GATE III z 1 am exempt from the licensing requirements as I am a -ROM: TO: m ) licensed architect or a registered professional engineer SIZE of NO. OF INSPECTORS z acting in m\' professional capacity (Section -051. Bus- (EXISTING BLDG. STORIES SIGNATURE oiness and Professions Code). !FINAL APPROVAL U_ Lic.or Reg.No. Date PRESENT USE OF BUILDING 7_4/J HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 140 F1a=1C ON LOT AND USE I hereby affirm that I am exempt from the Contractor's i License Law for the following reason (Section 7031.5. Busi- I i ness and Professions Code): NO. PARKING s° ❑ I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section i I 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING e I lierebv affirm that there is a construction lending agency ( ` I for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. � In Sbams . I Lender's Name it PROPOSED MAX. OCC. ' Lender's Address 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 treetatives of this County toe I TOTALFEE 25.00 i the above-meatifor inspecti n ptt es. ,� SEE REVERSE FOR EXPLANATORY LANGUAGE ' I - Signa tre o rmittee 7 Date I WORKERS'COMPENSATION DECLARATION CE 875(11.84) MISCELLANEOUS APPLICATION ICE 876 [ hereby affirm that I have a certificate of consent tself f COUNTY OF LOS ANGELES BI % IJILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or _ a certified copy thereof(Sec.3800,Lab.Q. Policy No.a Coma al Tnd niBUILDING —Q p riylYl 13Sfrl- � t�7 p FOR APPLICANT TO FILL IN ADORE Ss �� • ❑ CeItrf �r'I& is hereby furniSRe{l y XX ADDRESS 5827 N.ROsemead Blvd. LOCALITY Certified copy is filed with the county building inspection I LOCALITY NEAREST department. yy{+ N/W Corner of Rosemead & LasTtuia C`418 IT. Datel/13197 Applicant Bill F•ri _kgcm NEAREST DISTRI NO. GR P TYPE •CESSED BY CROSS ST. Rosemead & Las Tunas Drive ,1 4 y CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' 1i•� e LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO.See at t I K MAP, HIGHWAY HOT (CIRCLE) STATE MAJOR SECOND LOCAL NO.OF BLOCS. (This section need not be completed if the work involved TRACT NOW ON LOT USE 0.. ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) I USE OF SIZE OF LOT EXISTING BLDG. } I certify that in the performance of the work for which this I " D-, permit is issued,1 shall not employ any person in any mannelk3q OWNER of buildingS.Lew & AssociatesZa so as to become subject to the Workers'Compensation Laws. OCCUPANCY GROUPMAIL ELI D. ADDRESS 5825 Rosemead Blvd. U Date Applicant NOTICE TO APPLICANT: If,after making this Certificate of I CITY Temple City TEL NOTICE OCCUPANT LOAD N Exemption, you should become subject to the Workers' i APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- ❑ with comply with such provisions Or this permit shall be TRAILER USEGEOLOGY INSPECTION No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION Panic Devices OCCUPANCY INSPECTION 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- I 4 NO. OF EXITS F ness and Professions Code,and my license is in full force anix ,I effect. ,I Name of business SP/ICE9r'SPACES � PROVIDED License Number Lie. Class Value Priced Clothing, Inc. DBA: C & R Clothiers LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROMI TO: licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL LIC.Or Reg.NO. Date PRESENT USE OR BUILDING HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ."" F EVE ON LOT AND USE 00 1 hereby affirm that I am exempt from the Contractor'sA(-/9�q License Law for the following reason (Section 7031.5, Busi- [ICIC)J-`011)1 "u"7:_I"' ness and Professions Code): I No. PARKING Y1`6 ,((58 , {{--Psi�j I [, as owner of the property, will do the work and the SPACES PROVIDED i_ `- 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 Retail.;Sales for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). Lender's Name PROPOSED MAX.OCC. - Lender's Address 1 certify that I have read this application and state that the PERMIT FEE 9-5.00 above information is correct.1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, +M and hereby authorize representatives of this County to enter TOTAL.FEE 25.00 upon the abov e i ed erty for'nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE XX � XX 1/13/97 l a Signa urc of Permittee Date I