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Home My Public Portal About6336 ROSEMEAD BLVD_Miscellaneous__ r ORKE??S'COMPENSATION DECLARATION CE 875(2-80) 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 a certified copy thereof(Sec. 3800;Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS CC//V t/ ❑ Certified copy is hereby furnished. BUILDING3 ^ may/ J LOCALITY' rA ADDRESS 6 tI ��UV ((, Certified copy is filed with the county building inspection 1.0, NEAREST department. 1, LOCALITY `� �.r C-1,41 -1 CRo SS ST. Date - Applicant EAREST G �r t DISTRICT_N/p G gOUP TYPE PRO SED BY CROSS ST. 46 �� ` ',d /IY //�i7� CONST/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL \�J r () v V V COMPENSATION INSURANCE DESCRIPTION LO NO. BLOCK Mpp �,//.2, RIGHWAV O_ rvo. !N (CIRCLE) STATE MAJOR SECO D LOCAL tZ NO. OF BLDGS. O (THIS section erm need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.) n USE OF V SIZE OF L EXISTING BLDG. ir 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 WNE so as to become subject to the Workers' Compensation Laws. AIL 0 OCCUPANCY GROUP - W AD RES ��► QU) Date Applicant z NOTICE TO APPLICANT: If, after making this Certificate of cI N7.< 53 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 E] GEOLOGY INSPECTION C1 No Spec. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that.l am licensed under provisions of Chapter SAFETY PERMIT L 7 (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 REq'D E:= PROVIDED License Number Lic.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 acting in my professional capacity (Section 7051, BUS EX IS ING BLDG. STORIES SIG ATURE iness and Professions Code). ESENT US F BUILDING FINAL APPROVAL �✓ �.� Lic,or Reg.No. Date F HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDING VV ON LOT AND USE !3 2 Q 885A I hereby affirm that, I am exempt from the Contractor's # o • s • 8 License Law for the following reason (Section 7031.5, Busi- 0 0 0 0 0 0 • z NO. PARKING ,10. 17k-85 0. 1 7= OU 5 Hess and Professions Code): SPACES PROVIDED 1, 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). OPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency l/ O,(1Cr B I 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 PERMIT FEE I certify that I have read this application and state that the 10 above ineFat'i'IT is correct.I agree to comply with all County ISSUANCE FEE ordina e, o tate laws relating to buildii -TOTAL FEE Aandhrepa tatives of County to enter ent d perty inspe on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ittee Date 111ORICERS'COMPENSATION DECLARATION 76M444 I MISCELLANEOUS APPLICATION J CE 875 (11-84) - 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 copy thereof(Sec. 3800,Lab.C.). Policy No. CompanyFOR APPLICANT TO FILL IN ADDRESS / ADDRESS95 d FICertified copy is hereby furnished. xx ADDRESS 3 6 Jc� LOCALITY S' ,m ec't Certified copy is filed with the county building inspection LOCALITY NEAREST department. Xx CROSS ST. Date --Applicant NEAREST DISTRICT NO. GROUP TYPE P ESSED BY CROSS ST. F Dp CONST. C:IIR'I II ICA"I'E Of EXEMPTION ( ROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF SLOGS. (flus 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 OP SIZE OF LOT TING BLDG. 1 certify that in the performance of the work for which this c� permit is issued, I shall not employ any person in any manneltX OWNER O but din so as In beconic subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS r- Datc—___ Applicant_ _ C- NOTICE TO APPLICANT: If, after making this Certificate of CITY No� '7i �0 OCCUPANT LOAD v� 173 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. deenied revoked. OCCUPANCY INSPECTION Panic Devices I.I('ENSL:U CONTRACTORS DECLARATION I lie reby afflrin that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) a 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS mess and Professions Code, and my license is in full force anix effect. Name of business PARKING SPACES REO D E�:= PROVIDED License Number ----------._--- Lic. Class IAJ,4TE , /4CvL, LIMITED TIME USE Date— DATE DATE El FROM: TO: I ani exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer SIZE OF NO. OF IN CTO R'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SPATURE i iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg. No.___ __—_ __ Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I ii li iS_i•-;it I:t ... hereby affirm that I ant exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi ='I `':' 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). 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.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address.--------- -- __-- -- — 95. 00 1 certify that I have read 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 authorize representatives of this County to enter TOTAL FEE 25 -00 upon the above-mentioned properly for inspection purposes. _ I /� f SEE REVERSE FOR EXPLANATORY LANGUAGE XX_,� L��l xX rO > q16 WORKERS'COMPENSATION DECLARATION CE 875 (11-841 MISCELLANEOUS APPLICATION CE 875 " I hereby affirm that 1 have a certificate of consent to sett COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or rr,l a certified copy thereof(Sec. 3800,Lab.C.). '`��"►� Polity No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS / ADDRESS 41/1J(o Certified copy is hereby furnished- X BUILDINGr ADDRESS �`�3 ft0S rltpp LOCALITY Certified copy is filed with the county building inspection LOCALITYNEAREST department. Temple City CROSS ST. Date Applicant NEAREST DISTRICT NO. I GROUP ITYPE P ESSED BY CROSS ST. ✓ CONS I CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ✓ ';rep COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL i NO. OF BLOGS.(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 V) I SIZE OF LOT EXISTING BLDG. ; I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any mannerOWNER so as to become subject to the Workers' Compensation La',vs, MAIL OCCUPANCY GROUPE4:1 „! Date ADDRESS Applicant rE NOTICE TO APPLICANT: If, after making this Certificate of CITY - No.. OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: ` Compensation provisions of the Labor Code, you must forth El�4r) with comply with such provisions or this permit shall be TRAILER USE E] GEOLOGY INSPECTION No Spec. Know]. deemed revoked. ` El I LICENSED CONTRACTORS DECLARATION OCCUPANCY IN SPE CTIONIM Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter =4I 9 (commencing with Section 7000) of Division 3 of the Busi- SAFETY PERMIT ❑ ILIST ITEMS BELOW) NO. OF EXITS ness and Professions Code, and my license is in full force and effect. PARKING REq'D D PROVIDED O ! License Number Lie. Class SPACES— LIMITED TIME USE Contractor Date DATE DATE t--ROM: I am exempt from the licensing requirements as I am a TO: licensed architect or a registered professional engineer SIZE of NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bas- EXISTING BLDG. STORIES SI TURE inessand Professions Code). FINAL APPRVAL PRESENT USE OF BUILDING Lic.or Reg.No, Date10 -_ ►^{ ` ! HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS V ON LOT AND USE 1 hereby affirm that I am exempt from the Contractor's I ,T) License Law for the following reason (Section 7031.5, Busi- i 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 y I 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY g PROPOSED USE of BUILDING c./ I hereby affirm that there is a construction lending agency I v! for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). — Lender's Name t PROPOSED MAX. OCC. 1 Lender's Address • PERMIT FEE 25.00 7 I certify that I have read this application and state that the "A above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, �QI and hereby authorize representatives of this County to enter TOTAL FEE 25.00 J I upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE s 5—�A� As P - Signature of Permittee Date t�