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Home My Public Portal About6276 ROSEMEAD BLVD_Miscellaneous__ WOKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUSCE 875 (2-80) APPLICAT0ON i heltiby affirm that 1 have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES -BUILDING AND SAFETY'DIVISION a certified copy thereof(Sec 3800,Lab C) Policy No ;CompanyFOR APPLICANT TO FILL IN BUILDING / a ADDRESS Ceitified'copy is,hereby furnished BUILDING LOCALITY ADDRESS 0 Certified copy is,filed with the county building inspection NEAREST department` LOCALITY CR ST. 1 Date Applicant NEAREST DISTRICT NO. OUP TYPE PRO ED BY 'CROSS ST 1 �_ )I , �J CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J (JO (� DESCRIPTION LOT BLOCK COMPENSATION INSURANCE :. `"AP "'�""'A� STATE MAJOR SEC D LOCAL } NO. OF SLOGS. No (CIRCLE) d (This section need not be completed-if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O by the:permit is: for one-hundred dollars ($100) or.less.) usE of (/•^/'.Z SIZE OF LOT EXISTING BLDG v 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 Z0I ® U so as to become•sub)ect to the Workers' Compensation LawsMAiL I OCCUPANCY GROUP �� W I ADn Date ,.Applicant �•• DRESSN TEL OCCUPANT LOAD, Z NOTICE TO APPLICANT If, after making this Certificate of cITY 1 No. I —�p 8 - 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 proVisiUnS deemed revoked " ❑or this permit Shall be TRAILER USE GEOLOGY INSPECTION ❑ 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) 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 REq'D O PROVIDED O SPACES License Number Lis Class- LIMITED TIME USE Contractor 'Date DATE DATE FROM 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 i acting in my professional capacity-(Section 7051,'Bus- EXISTING BLDG. STORIES SI NATURE loess and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING Lie or Reg,No Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS • ON LOT AND USE - 7 I hereby affirm that I am exempt from the Contractor's ' License Law for the following reason (Section 7031 5,-Busi- ness and Professions Code) SNO P PARKING SPACES PROVIDED _ 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) PROPOSED 6sE OF BUILDING 0 0 0 0i� C� �ti :136 a CONSTRUCTION LENDING AGENCY, 1 hereby,affirm tKat there is a construction lending agency for the performance of the, work for which this permit is e`s o e o 0 0 issued(Sec 3097,Civ C) 12(]5 "$Jr Lender's Name PROPOSED MAX. OCC _ Lender's Address PERMIT FEE I certify that 1 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 and hereby uthorize representatives of this County to enter upon the ove-me tioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE , Signatur f Permittee Date - WOIQKERS'COMPENSATION,DECLARATION 5CE 87 (2-80) _M I SC E L LA AE O US 'APPLICATION I hereby affirm that I have certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of•Workars'Compensation Insurance, e,or , a certified copy thereof(Sec 3800,'Lab C) Policy No Company FOR APPLICANT TO,FILL IN Bu1LDING n ❑ ADDRESS' OC Certified copy is hereby furnished UILDING Q// O LOCALITY 1. 19 ❑ 1 ADDRESS .) ,(7 , Certified copy is filed with the county building inspection 07- LO LITY NEAREST department ' cRoss sr. ' Date Applicant NEAREST ) DISTRICTNO GR TYPE, IPROCE ED BY CROSS ST _ 'CON CERTIFICATE OF EXEMPTION FROM WORKERSLEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY } - _ NO (CIRCLE) STATE MAJOR SECON OCAL O (This.section need not be completed lthe work involved TRACT NOW ON LOT NO OF BLDGS•• USE ZONE SPECIAL CONDITIONS V by the permit,is for one hundred doll ($100),or less.) USE OF C� SIZE OF LOT EXISTING BLDG I certify that in the performance of the work for which this , 0 permit is issued, I shall not employ any person in any manner wNER - U so as to become subject to the Workers' Compensation LawsIL OCCUPANCY GROUP- ; �� W - ADDRESS 3 � L �// �" "• _ l . _ t/� Date Applicant V NOTICE TO APPLICANT If, after making this Certificate of CITY WCY(71/%" NO �� ' �� OCCUPANT LOAD' z Exemption, you should become subject to -the Workers' APPLICATION FOR EXIT HARDWARE. wtCompensation provisons of the Labor Code, you must forth- - ih comply with S'u'ch provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION deemed revoked. ❑ ❑ No Spec. Knowl. ❑O LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 - REO'D O PROVIDED' O SPACES License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE 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 Illy professional capacity (Section 7051, Busr EXIST, G BLDG: _ - STORIES SI NATURE mess and Professions Code)• FIN'AL�APPROVAL PRESENT USE OF BUILDING l , Lic or Reg.'No Date' dTl O HOME OWNER-BUILDER DECLARATION NO EXISTING BUILDINGS ON LOO T AND USE, � :2 4 61.7 A . I hereby affirm that I am exempt from the Contractor's # 0 0 0 0 8 8 License-Law-for the foll-owing reason (Section 7031 5, Busy- y m ness and Professions Code) NO. PARKING •Pa'�(�=O S z SPACES,PROVIDED EJI,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). 3 +' OPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency , 0 V%wi- - ' for the ,performance of the work for which this permit is' t 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 FIEE and hereby authorize representatives of this County Jo enter upon the above-mentioned property for inspection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE I ,Signature of Permittee Date