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Home My Public Portal About6270 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 876(2-80) IV11 SC E L LA N E O U S APPLICATION I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' rs'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) . Policy No. Company FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is hereby furnished. ISU'ILDING f�` LOCALITY ADDRESS E� ❑ Certified copy is filed with the county building inspection NEAREST department. OCALITY .� CROSS ST. in Date Applicant NEAREST DISTRICT NO G P TYPE / PRO ED BY. CROSS ST. �`, CONS7./ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL %V6 COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECO D LOCAL _d NO. OF BLDGS. (This section need not be completed if the work involved < TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS OU by the permit is for one hundred dollars ($100) or less.) USE OF IZE OF LOT EXISTING BLDG. - I certify that in the performance of the work for which this Q permit is issued,.I shall not employ any person in any manner OWNER t V so as to become subject to the Workers' Compensation Laws. MAIL ' OCCUPANCY GROUP 0 -V LU DDR SS Date Applicant Ad PQ&R MA2a Ito TE NOTICE TO APPLICANT: If, after making this Certificate of cITY Ct rvo 01'@).a25-1 al OCCUPANT LOAD z Exemption, you should become subject to the Workers' APPLIC ION 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 deemed revoked. ❑ No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION. OCCUPANCY INSPECTION Panic Devices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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. - - ,SPACES REO',D PROVIDED - License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE FROM: To: ❑ I am exempt from the licensing requirements as'I am licensed architect or a registered professional engineer SIZE OF a, NO. OF INSPECTOR'S acting In my professional capacity (Section .7051, Bus- E (STING BLDG. STORIES SIG),ATURE iness and Professions Code). FINAL APPROVAL RESENT USE OF BUILDING S r Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS' # 0 " . . 88 0oS8 ON LOT AND USE - I hereby affirm that, I am exempt from the Contractor's D,0 0 D D v 0 z License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING �J 1 Z'_8 Jr SPACES PROVIDED G 3 ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). f PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is aconstruction lending agency If for the performance of the work for which this permit is fi i l 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, TOTAL FEE a d hereby authorize representatives of this County to enter the abo - e tion rpropert r in ection pur ores. SEE REVERSE FOR EXPLANATORY LANGUAGE I ' Signature of PerYnittee D to ' WORfKERS'COMPENSATION DECLARATION. CE 875 (2-80) IVB I SC E L LA N E113 U S APPLICATION I hWby-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. Company FOR APPLICANT TO FILL IN BUILDING ❑ ADDRESS Certified copy is hereby furlti$h d. BUILDING 62 �� V LOCALITY \ ADDRESS ❑ Certified copy is filed with the county building inspection NEAREST department. \ LOCALITY A �p�� CROSS ST. Date Applicant NEAREST DISTRICT IIO. G OU ' TYPE PROC SED BY CROSS ST. �0 Act a-kA 5, /1(/ � CONST CERTIFICATE OF EXEMPTION FROM ORKERS' LEGAL vVA / COMPENSATION INSU CE DESCRIPTION LOT NO. BLOCK MAP '/! f IGHWAy NO. �U(J (CIRCLE) STATE MAJOR SEC ND LOCAL a NO. OF BLDG 0 (Tills 50CtlOn need not be completed if th or involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS U by the permit is for 'one hundred dollazs ($ less.) j� USE OF SIZE OF LOT - EXISTING BLDG. ��✓ 0 I certify that in the performance of the work for whit is permit is issued, I shall not employ any person in any marine OWNER �� S1�A� I I�� F— so as to become subject to the Workers' Compensation Laws. j of c �jLp/� .I� is OCCUPANCY GROUP',' W AD ULESS L�w�J6 -3 Wk%I1�QC (3LL )t ^^� Date Applicant { C NOTICE TO APPLICANT: If, after making this Certificate of ctrY �1� �2r i CA, Not. �b 5� 1 OCCUPANT LOAD Z 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 INS ECTION deemed revoked. ❑ ❑ No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPE ON❑ Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 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. SPACES REO'D O PROVIDED O License-Numbe' Lic. Class LIMITED TIME USE Contractor Date • DATE DATE ❑ ROM: TO: I am exempt from the licensing requirements as I am a licensed architect-or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S NATURE iness and Professions Code). FINAL A ROV AL PRESENT USE OF UILDING Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION No. of Exts UNG BUILDINGS ON LOT ANyf USE I hereby affirm that, I am exempt from the Contractor's fl ��\S2�-85 9, 1A License Law for the following reason (Section 7031.5, Busi- ,;ness and Professions Code): . No. P KING SPAC SPROVIDED �❑ 1, as owner of the property, will do the work and thestructure is not intended or offered for sale (Section 7044, Business and Professions Code). ROPOSED USE OF BUILDING —85 CONSTRUCTION LENDING AGENCYI hereby affirm that there is a construction lending agencyfor the performance of the work for which this permit isissued(Sect 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, TOTAL FEE an ereby authorize representatives of this County to enter u on he abo -m ntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 111,1,,,, �2.►^gs Signature of Permittee Date