HomeMy Public PortalAbout6324 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 675 (11-84) MISCELLANEOUS APPLICATION {1
CE 875 LI
I lie ti r a cert that i have a certificate of consent to c 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 furnished. UILD ING
DDRESS A— ` ` � LOCALITY
k/' ^ rjr
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. k'.- Gl CRoss ST.
Date Applicant EAREST DISTRICT NO G P TYPE / PROC 57SED BY
CROSS ST. � r �. CONST. (,/'/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECO LOCAL
NO. OF BLDGS.
(This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF �i
I certify that in the performance of the work for which this ZE OF LOT EXISTING BLDG. o
permit is issued, I shall not employ any person in any manner V OWNER G, 1 C �
so as to become subject to the Workers' Compensation Laws. AIL i OCCUPANCY GROUP
DRESS 1160 ~
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY CSS T O OCCUPANT LOAD
V
Exemption, you should become subject to'the Workers' z
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.
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 I�
effect. PARKING
SPACES REQ'D PROVIDED l�
'
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE D ATE
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF FROM: To: INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- E ISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL /�7
PRESENT USE OF BUILDING `G
Lic.or Reg.No. Date61
,Vkf - 5
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
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): NO. PARKING
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). 3`i= FEE
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency y` _ Cu.l , 1")j;()f)—'!ii`f yt`11.I =;'r°.
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
PERMIT FEE `vim
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
,!on the -mentioned proper y for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE ��D
SignatuX of P Dat �y('
WO%ERS'COMPENSATIONDECLARATION 76M444.
CE 875 (11c84)_ MISCELLANEOUS APPLICATION
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 p
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT T A
FILL IN BUILDING
❑ DDRESS
Certified copy is hereby furnished. BUILDING
ADDRESS LOCALITY ( r
Certified copy is filed with th coun building inspectio NEAREST
dede tc X1 LOCALITY
CROSS ST.
Date I- Applicant EAREST DISTRICT NOI GROUP TYPE PROCESSED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. ,i BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF HLDGS.
(This section need not be completed if the work involved TRACT NOW ON IOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
d
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. C:)
permit is issued, I shall not employ any person in any manner OWNERc�
so as to become subject to the Workers' Compensation Laws. MAIL C 0. VO OCCUPANCY GROUP o
ADDRESS Y -
Date Applicant a
NOTICE TO APPLICANT: If, after making this Certificate of CITY NoTEL' 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 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
effect. PARKING
SPACES REQ'O D PROVIDED
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 my professional capacity (Section 7051, Bus- E (STING BLDG. STORIES SI NATURE
iness and Professions Code). FINAL APPROVAL
77
Lic.or Reg.No. / PRESENT USE OF BUILDING�� �T�Date�C�
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's 7 7
License Law for the following reason (Section 7031.5, Busi- • e o •
ness and Professions Code): NO. PARKING + o 0 0 0 z
I, as owner of the property, will do the work and the SPACES PROVIDED O a 2 7`• $7
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY N 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(See. 3097,Civ.Q. //\\
Lender's Name ��� � _ V
PROPOSED MAX. OCC.
Lender's Address
•!'''• ;'2 ''. PERMIT FEE VIJ �
I certify that I have read.ti s`application and state that the r
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, Oa
and hereby authorize representatives of this County to enter TOTAL FEE
u on the above-mentioned.property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
i WORI:ERS'COMPENSATION DECLARATION 4
CE 875 It 1-84) M I SC E LLA N EO U S APPLICATION
I CE 87
;•I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure., ck a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800_.Lab.C.).
Policy No.-Com
pany FOR APPLICANT TO FILL IN BUILDING
an
DDRESS
Certified copy is hereby furnished. BUILRDEING �/I_ - --L.--
I Certified copy is filed with the county building inspection�' LOCALITY -T !1 qr V f3 NEAREST
department. CROSS ST.
Date applicant NEAREST �e_ DISTRICT NO. CONST.// CESSED BY
• CROSS ST.
i CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
No. (CIw CLe) STATE MAJOR SECOND LOCAL
( NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (S100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. i� }
I certify that in the performance of :he work for which this
permit is issued. I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. ( MAIL - L1ZLC � OCCUPANCY GROUP
tY ADDRESS r - �/.` =
Date Applicant rr
rEL. / OCCUPANT LOAD
NOTICE TO APPLICANT: if, after making this Certificate of CITY e e"
No. �p
Exemption, you should become subject to the Workers' 1 a 6 APPLI ION FOR EXIT HARDWARE: CC
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or thispermit shall be ( J
TRAILER USE I17 GEOLOGY INSPECTION ❑ NO Spec. KnOWI,
- deemed revoked. permit
LICENSED CONTRACTORS DECLARATION
I 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 p r
PARKING IDED
effect. REO'D PROV
� � SPACES
License Number Lie. Class
LIMITED TIME USE
n Contractor Date DATE - OATE
L
` ❑ FpOM: TO:
am exempt from die licensing -equirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
y TORIES SI NA7UR
? acting in m}' professional capacity ;Section 70.1, Bus-
EXISTING BLDG. S
_ iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
Lie.or Re_z. No. Date ,
4'
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ��t l
ON LOT AND USE
1! -
I hereby affirm that I ant exempt from the Contractor's �-
! License Law for the following reason ISection 70:1.5. Busi-
ness and Professions Lode): NO. PARKING /t� / -
SPACES PROVIDEDii 1
1, as owner of the property. will do tile 7/`j
e work and the -.
structure is nor intended or offered for sale (Section
'044.Business and Professions Code).
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is I 1
issued(Sec. 3097,Civ.C.). I
Lender's Name I
PROPOSED MAX. OCC.
Lender's Address
( PERMIT FEE V
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,
and hereby authorize representatives of this County to enter TOTAL FEE '�J UU
! _ I upo the a ove-mentiotied property for inspection purposes.
r�7 SEE REVERSE FOR EXPLANATORY LANGUAGE
Siznature of P:r^.tit:ze Date
WUKNLK3 LVIvIrCIN3AIIUIV UCI.LHKHIIUIN 20-0063DPW12/90 Ir11D�.►GIL-LLH111GI%JV7 t1r[-L.It►t1A ►V 111
I hereby affirm that I hatle a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �
insur,:.rr� ce;6ficate of Workers' Compensation Insurance, or
a _ertiYa'd copy thereof (Sec. 3800, Lab. C.) ' J
Policy No. Company_ _ BUILDING ADDRESS FOR APPLICANT TO FILL IN BUILDING
ADDRESS 63- Zti .&Z9P 41/A
p
❑ Certified copy is hereby furnished. (� ? PCU LOCALITY t
❑ Certified copy is filed with the county building inspection CITY zIP
department. N CE GT GA . �j/78� NEAREST.
t, l Rarr QL vD
CROSS STLO�IQD�V —�'
Date Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRI NQ1, I OUP I TYPE OCESSED BY
CERTIFICATE OF EXEMPTION FROM WORKERS' q6O , w CONST/
COMPENSATION INSURANCE RAcr BLOCK LOT NO.
MAP HIGHWAY
NO. ICIRCLE) 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.)
I certify that in the performance of the work for which this OWNER TEL NO. I09
permit is issued,•I shall not employ Property U NM AC / - 3 -o?!
p p y •an y person in any manner ADDRESS
31
so as to'become subject to the Workers' Compensation Laws. f 4i5 OCCUPANCY GROUP
Date Applicant CITY ZIP
;NOTICE TO APPLICANT: If, after making this Certificate dR ��� 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 deemedTRAILER USE❑
revoked. GEOLOGY INSPECTION❑ No Spec.Knowl. ❑
❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
I hereby affirm that I am licensed under provisions of ChapterSAFETY PERMIT❑ (LIST ITEMS BELOW)
9(commencing with Section 7000)of Division 3 of the Business No.of EXITS
El
and Professions Code,and my license is in full force and effect.
PARKING•' REQ'D D PROVIDED D
License Number — Lic. Class �l0 SPACES
Contractor Date �(/ LIMITED TIME USE
DATE DATE
❑ I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer INSPECTOR'S
SIZE OF NO.OF
acting in my professional capacity (Section 7051, Business rXISTING BLDG. STORIES SIG E
and Professions Code).
Lic. or Reg. No. Date PRESENT USE OF BUILDING FINAL APPROVAL fp(8-r!u
i
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS D Ie
ON LOT AND USE
'"l hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and 1
'Frofesslons Code): NO.PARKING I
1,,as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale(Section 7044X PROPOSED USE OF BUILDING
Business and Professions Code).
ilk C �
CONSTRUCTION LENDING AGENCY
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.C.). PROPOSED MAX.OCC.
Lender's Name _ APPLICANT(POINT) TEL NO.
Lender's Address - ADDRESS
I certify that I have read this application and state that the
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
t -_mentioned property for inspection purposes.
. TOTAL FEE iJ�
c �I� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date.