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Home My Public Portal About6266 ROSEMEAD BLVD_Miscellaneous__ -1VORKERS'COMPENSATION DECLARATION CE 875 (11-84) M ISCELLANEOUS APPLICATION CE 875 I hereby affirm that 1 have a certificate of consent self COUNTY OF LOS A_-NGEL:ES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab.C.). Policy No Company FOR APPLICANT TO FILL IN BUILDING ADORES$ Certified copy is hereby furnished. LOCALITY XX BADILDINS 6166 IV. ROSC'/r)Ptcl— (31Vd Certified copy is filed with the county building inspection LO.CA-LJT_Y` department. l� �' CA 9179v NEAREST CROSS ST Date Applicant NEAREST DISTRICT NO GROIJ P TYPE ESSED BY CROSS ST O �i CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Q COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NOOF LOGS NG. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOW. ONBLOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. p 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manne OWNER of building: ru so as to become subject to the Workers' Compensation Laws OCCUPANCY GROUPE?:] °= ADORE$$ /.3$ 13�, {Nh�ff'ie!' B/rk1, SLli�C 202 - - — Date Applicant w TEL. Z O- NOTICE TO APPLICANT If, after making this Certificate of clry �//ji jrjZl e/' No OCCUPANT LOAD��0 69 3-• y cn 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 I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busr SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO OF EXITS ness and Professions Code, and my license is in full force a-XX effect of business PARKING _ D License Number - Lic. Class oust i �h�e�fit�hvr,e�t� SPACES RfiG'D =J PROVIDED LIMITED TIME USE--_- _ Contractor Date DATE DATE I am exempt from the licensing requirements as I am a , 'ROM TO licensed architect or a registered professional engineer srzE OF No OF INSPECTORS, acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATOR inessand Professions Code) FIMAL APPROVAL iAly LIC or Reg No Date PRESENT USE OF BUILDING _i HOME OWNFR-BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE �`� ��, .mow �'�-'f `� ('—!r'•• ^ I hereby affirm that I ani exempt from the Contractor's " License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING [, 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 (� 1 hereby affirm that there is a construction lending agency e. owQ. for the performance of the work for which this permit is 0 "I issued(Sec. 3097,Civ.C) Lender's Name PROPOSED MAX. OCC Lender's Address PERMIT FEE 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 representatives of this County to enter TOTAL FEE 25 .00 upon the above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE -- XX ,, �� XX � �1 y j —3ienature of Permof Permittee Date WKERS'COMPENSATIONDECEA)+vt�""TN 76M444 CE 875 (2-80) MISCELLANEOUS ISCELLppEOUS APPLICATION i--hereby affirm that I have certificate copse't to self 'Kure, or a certificate of Workers' rs'CompensaS s�ra ce,o '�t COUNTY OF LOS ANGELES BUFLDING AND SAFETY DIVISION a cert.fied copy thereof(Sec 3800, Lab C) .r Policy No Company ADFOR APPLICANT TO FILL IN ADDRESS Certified copy is hereby furnished t BUILDING 6 A 6 p / �O-5�� LOCALITY V I DRESS N� Certified copy is filed with the county building inspectio �� NEAREST department Lo ALITY / Ar" G/ �e CROSS ST Date Applicant EAREST j DISTRICT N -f-GR UP TYPE / PRO SED CROSS ST.1'J OIt-I y G'�/ /' CONST ` CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V DESCRIPTION LOT.NO BLOCK MAP • HIGHWAY COMPENSATION INSURANCE No h �� (CIRCLE) STATE MAJOR SE ND LOCAL Q (This section need not be completed if the work involved No of BLDGs TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.) : USE OF SIZE OF LOT EXISTING BLDG. I certify that•m the performance of the work for which this O permit is issued, I shall not employ any person In any manner owNER �� S'!� /�� v U so as to become subject to the Workers"Com pensatton Laws 44AIL / OCCUPANCY GROUP !—C�� W Date Applicant A DDRESS 3 �/(/ h I �i/`�__ d CL NOTICE TO APPLICANT If, after making this Certificate of W�)/f�9��, NO-TF '�Club�13 OCCUPANT LOAD -- , Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE with.comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec. Knowl. ❑� • deemed`revoked � P - OCCUPANCY INSPECTION f Panic Devices LICENSED CONTRACTORS DECLARATION �p ' - �� I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO.,OF EXITS .9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code,'and my license is in full force and PARKING. effect REO'D PROVIDED SPACES License Number Lic Class ___ __• - _ LIMITED TIME USE Contractor Date DATE DATE El I am exempt from the licensing requirements as I am a FROM' 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 mess and Professions Code) FINAL APPROVAL _ RESENT USE OF BUILDING Lic or Reg No Date - HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ;2 2 5 4,V A ON LOT AND USE ' - I hereby affirm that I am exempt from the Contractor's # 0 0 0 0 8 8' License'Law for.the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING O o e e o s a In SPACES PROVIDED _ ❑ I, as owner of the property,,will do the work and the 07.25-785 structure is not Intended or offered for sale (Section 7044, Busmess and Professions Code) • ROPOSED USE OF BUILDING - + CONSTRUCTION LENDING AGENCY �R /g`��%�- I hereby affirm that there is a construction lending agency for the performanceof the work for which this permit is issued (Sec 3097,Civ.C) , Lender's Name - PROPOSED MAX.. OCC Lender's Address' • PERMIT FEE , 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 V ordinances and State laws •relatmg'to building construction, TOTAL'FEE and hereby. authorize representatives of this County to enter 1\\Jl uppn • ove-m ntjQned+property for Insp tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 11 Signature of Permittee Date