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Home My Public Portal About6515 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATIONDECLARATION 76M444 MISCELLANEOUS APPLICATION Compensation 1 hereby affirm that I have a certificate of consent to self CE 875 (2 80)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 ❑ C �,1. ADDRESS _ Certified copy is hereby furnished. nDowEss bJ I .� _ �� -�L0 --`' 1 6 .I LOCALITY ❑ Certified copy is filed with the county building inspection f' department. Louur rr 'T - Ji t.� C,, NEAREST "' cwoss sr. Date Applicant NEAREST. '- l DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. LL.. Y 1 r L� M1P4h CONST. } CERTIFIC YTE OF EXEMPTION FROM WORKERS' LEGAL d COMPENSATION INSURANCE DESCRIPTION LOT No. BLD.. N.P ID�wA (CIRCLE) STATE MAJOR SECOND LOCAL O L. by t section need not be completed d If the Work involved NO. OF LOT USE ZONE SPECIAL CONDITIONS Li (This TRACT NOW ON LOT by the permit is for one hundred dollars ($100) or less.) w � USE OF _I SIZE OF LOT EXISTING BLDG. Icertify that in the performance of the work for which this . . 1.1- permit permit is issued, I shall not employ any person in any manner Z'OWNER k 4- !t�0sJ so as to become subject to the Workers' Compensation Laws. HAIL OCCUPANCY GROUP cc AOO..SS / `i Date Applicant TEL - - 'I cc NOTICE TO APPLICANT: If, after making this Certificate of ITY lJ 1' - No. i '*I OCCUPANT LOAD 0, Exemption, you should become subject to the Workers' :) APpLI'CATION FOR EXIT HARDWARE: _ Compensation provisions of the Labor Code, you must forth- LLD with comply with such provisions or this permit shall be TRAILER IISE 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 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: II -1' effect. SPACES REO'D D PROVIDED 1 License Number Lia Class J LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a licensed architect Or a registered professional engineer SIZE of ND. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). ( FINAL APPROVAL PRESENT USE OF BVILDING Lie.or Reg.No. Date 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. PAR IROKIN SPACES PROVIO EO Y111 9 0 ❑ 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). PR ovos£D USE of BUILDING �( ,-� t= C 9 ri-}Q—Cn 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.). Lender's Name PROPOSED MAX. Oce. Lender's Address PERMIT FEE I certify that I have read this application and state that the above information is correct. 1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize represen�Yexff' this County to enter pon t above Ienti n pry inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �- I) -�`� Sig lure of Permittee Date \\OR61 RS (OkIPI NSA IION UI(LARAIION CE 875 (11 841 MISCELLANEOUS APPLICATION CE 975 • 1 Bttreby affirm that I have a certificate of consent to CIH COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION "lore or a cernficate of Workers (ompensation Insurance,or I terrified copy thereof ISeL 3800,Lib C) PohLy No — __(unlpmy- FOR APPLICANT TO FILL IN auuDlNa AO Dw[u FjCerllhad ropy is hertby furnished uomo b ` � 6 LOCALITY RCS• `' �` Certified s.opv 1s filed loth the county lou ddsrig Inspect lois oewurr I clEi oo it dep Ili"lentaXAL 1)11c_ ______ _Appllttnt— _ ___ NEAREST DISTRICT NO DaoUP TYPE IWCESSKD Or CROSS ST WLocK O rj /� BONS ( I R 111 1(All Or EXEMPTION 1 R N(WORKERS LEGAL O /d (OAIPF NSA(ION INSURAN(I O,acwvnoN Lor NO w.Bw• jc we LAl STATE Mwrow SECOND LOCAL IND no Of BLDue I (This section need not In completed if the work involved TRACT rsOW ON Lor ICE ZONE SPEtvwL to xo ITIONS by the permit Ia for one hundred dollars (5100) or less.) LIS[or SIZE OF LOT [,Fenno BLDG I Lertdy that 1n the performanLC of the work for which th s� permit n Issued, I %hill not employ any person m any mann -NKR of buildin �- G+ Ia to bel Orale snhlttt to OIL Worker% (umpensahun I nwa MAILOCCUPANCY GROUP ee ADDRESS [J Dale _ __ Appl,.int---_ — t" NO IK I 10 APPI K ANI If after making this Certificate of CITY NO IL OCCUPANT LOAD N I semplron you should become subject to the Workers — Iompensattun provisions of the Labor Code you must forth, APPLICATION FOR EXIT HARDWARE with comply with wtIl pm+tsiom or this permit shall be TRAILER USE 0 GEOLOGY INSPECTION No Spec Know] deemed resoktd I R I NSI 1)(ON 1 RA( I ORS DLC LARATION OCCUPANCY INSPECTION Panic Devices -- I hLrt b) dhnu Ilul 1 4111 IlLenwd under ptovi mns Of(hapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (comBust, with SeLIS+n 7000) of Division 3 of the BusNo or E,rr• mesa Tnd Pwfesaons(ode and oil license Is in full force and c(fcct ame of business PARKING w,oD Pwo.IDED ¢ Q /� SPACES LIMITED TIME USE I Iona Numhn 1 (lass ISO$ Y/) A CR G(T �S I onlnLu+rDate_ I 1m exempt from the licensing requirements as 1 am a INSPECTOR htensed Trchnect or a registered professional engineer SIZE or xo or Is acting In my professional LapTmty (Section 7051, Bus- E,ISTING BLDG SroRFES t,y mess and Professions(ode) FINAL APPROVAL 11c or Reg No —_—_ _ Date— rw Es[nr usE or BUILDING IIOMI O\VNI R NIIILUF R DECLARATION NO or EKunRa BUILDINGS v b �b ON LOT AND LIS[ I hereby Blum tlnl I un exempt from the Contractors (� I nense I aw for the lollo%mg to lam (SeLllon 7031 5 Bust ness and Professions(odej NO PARKING 1, is owner of the proper(I will do the work and the °PACKS PROVIDED structure Is not intended Or offered for sale (Section 7044 Business and Professions(ode) (ON SI RU( I ION LLNDI NG AGLNCY Pworoe[B LIES or BUILDING I Illicit) affirm tint there is a Construction lending agency For the perfurmnnce of IIIc work for whu.h this permit D owed ISec 3097 (w ( I I ender s N tine PworoSEO Mei-Bee I LndLr s Address ___ _ __ __ __- PERMIT PER 1 ccrldy Ilul 1 hoc rod Ih1s applrutron and stale that the above inform Ilion is torteo 1 (gree to comply with all County ISSUANCE FEE mdrnmces and Slate laws rehling to budding construction, lh and hereby auorue representatives of this County to entre TOTAL FE[ 25.00 upon the IMIve mentioned propert) fur mspcUlon purposes i SFE REVERSE FOR EXPLANATORY LANGUAGE � 1 1)Oe 1 AOR6LRSCOMPENSATION DLCL\RATION CE 875 l 1841 MISCELLANEOUS APPLICATION n GE 875 I hereov affirm that I have a certificate of consent o self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION music or a certificate of Rn orkers CompLsmon Insurance nr a certified cops thereof (S.L 3800 Lab C I I I� Poll. No Comoan) FOR APPLICANT TO FILL IN BUILDING ,; L, +D OR¢991f Certified cops 1, herebs furnISIlLd cow¢aax (05 1-9 AI)IIIed >,Vt LOCALITY )� 1 I Certified Lnp, Is tiled %tth the count, ouddme MSP,LtI LOCALITY NQwR ear department Temple City CROSS ST Date \oplicanl NEAREST twqOCES.ED BY twos. ST CE RTI EIL NTL OE E\C\IPTIO\ FROM 10R6ERS LEGAL !i d CO\IPE\S\TION INSL R\\(L oC9C1IFT ON LOT No aLocx I,.,•r "� STATE MAJOR SECOND LOCAL NO of BLD03 (This section need not he completed if the Mort. involve) -rt Ac- NOv on Lor ivs. •ons SPECIAL CONDITIONS by the permit Is for one hundred dollar, IS1001 or less ) visor I _ I sac or LOT EX LTINc aL.c I � (�( �1-_ Fj�7�� I _ertifs ,hat In ,hL ocr,Orinan,c vt he ,a,l o ,huh his - permit I, 6ni,d I ,hall not .mple, tm ae con n an, mann✓ O.NEw e So as ,O bewmL xl blt,t o ,he 1%orAe•s Co noeocition I Iva t OCCUPANC 3ROUP 4c 1 Gih �' - AAIL 11e - I Date \pelican, +o Drtssa = NOTICE TO APPLIC\\T If ,u e• mal.mL 'IS( art_Icve tit $J IT l�(J11L o- l8 _ 3dj OCCUPON- LCAC Exemption sou ,nould be,om- ,u*ice o hL \\o ¢e•' 1P°VCA-ICN =�❑ 9(IT -1�-CII,P° Lumpensoaon orosisions cit hL Libc• , vr,. ,ou must fr,h 1 ,suh LOmms I,Ith uvh vro it oils III III, -erne ,hail bL _R+IL¢R 1.9 NO SDec K-o-A ❑ deemed-L"Ke,i -' - LI(ENSEDCONTR\CTORSDECLARAi10\ OcuF+NCT IrvsFec-1°N7g Panic Cev'Pes I hereto. AI`Irm hat I am licensed unde•ore,i9rorsui( uotL- 9Ar C-Y PERMIT '-' (LIST ITEMS BELO v) 9 (commencing with SeL,ton -000) of Dni,fon ., of J e Susr No of EXITS ness knit P-ole„lon, Cod, and m, Iicense Is in 111 art: and of ft.L PARKING Sr C6] REOO � PROVIDED Linnsr ♦unber L c CIA„ i c- I�.J LIMITED TIME USE q Contractor hall D+TE z 1 am rsempt from the hLLnster repute neons n 1 m t license1 iLtm-d aro pr or ❑ re__isri-t a•olr,uonal -mm�elr Slze oR Np OI I SI ATUR S o Scut,_ n m pnttL„Iona! tr i_,t i, u -Ill Sus crlSnrvc aLvc I S-ORIF) SIG NATURE n mes,.nJ P•ot Lssicn,C ILII sa es[rvr USE or sululrvc FINAL APPROVAL Lm or Rre_ A,I Da I. /A HO`IE 0%%\1 R HLILDER DEC LIR \fIU\ NO or 1 EXISTING BUILDINGS � GG I herebON LOT wrvo u ¢v alrum that I am LNcmpt (mm Jle Con raLtor s 1 License Lav for the fo0uvkng reawn (SLLuon -'),I a Bu,l ,11 fess and P•oteastons Code) NO PARKING I as ,vner of the property "ill du he work and the sr"ceS .RONIoep atruc,nrc Is not iniLndcd or ottcred for .Je ,SCLtion l 7041 liu,ml,s and PTOIL,slons(odt) _ LO\STRLCTIO\ LLNDI\G \GI\(1 PROFOSQD us¢ of BU ILDIRo Pe S{a[e- I herebs atfum that there is a construction lending age, for thL pert OrmancL Of Ihl stork for ,shalt ,his Permit IS issued(SeL 3097 Cn C ) Lender s N MIL — PROPOSED MAX Dec Lenders Address M I Certif) that I have read this application and State that the PERMIT FEE 25.00 above information is LOOTLI I agree tO LOmpI) ss llh all County ISSUANCE FEE ord[na,ea and State Ia%% rLiating to budding construction and herebs aut orae r presentatnes of this County to enter TOTAL FEE 25,00 Ihe o en ed pr ert for ,Pec cion purpose 1/1'7 � /T? SEL REVERSE FOR E`CPLANATORI LANGUAGE Signature of Permittee ( D�e ! WORKERS' COMPENSATION DECLARATION zo�aDPW12le0 MISCELLANEOUS APPLICATION I hereby affirm that t have a certificate or consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION •rnsurc,or a certificate of Workers'Compensation Insurance, or u ( a certified copy thereof (Set 3800 Lab.C) Policy Na Company FOR APPLICANT TO FILL IN MLDING �LotyG�n ADDR[S6 8 Certified copy is hereby furnished x E 3 15 Es%( �o See vhn.ee.<� 9N A Lm. I Certified copy is filed with the county building Inspection emL�I'JfI G( �� ZIP q 1 7�^ NEAREST 7 department M 7 .roue nr eA+( '•i—T oe Date ' Applicant SIZE oftpTU J $ (_ NO OF 8L DGS NOW ON LOT Durnlcr No GROUP TYIa PROCESSED BY } CERTIFICATE OF EXEMPTION FROM WORKERS TRACT ?S eLLOCK LOT No C�� O ( I COMPENSATION INSURANCE N,. 'mow^Y U No ,asGvn STATE MAJOR SECOND LOCAL (Tars perms need r10[ behundred completed l me work involved ASSESSOR MAP BOOK PAGE PARCEL C by the pemlll IS for one Handfed d0118n ($100) Or IEss) LEIS ZONE ePECIAL CONO1T10H6 �O 11� 1 1 certify that in the performance of the work for which this UL I IO)31 �y W permit is issued 1 shall not employ any person In any manner t so u to become subject toWlrkers Compensation Laws ADDRESS �,J Z / OCCUPANCY GROUP en fi 13 IZiJ SC yr.U� ( Date/ Applicant I CITY ` �`-�(j41 ZIPYI —7 7S NOTICE TO APPLICANT 11' after making this Certificate OCCUPANT LOAD of Exemption you should become subject to the Workers APPLICATION FOR Compensation provisions of the Labor Code.you must forthwith EXIT HARDWARE comply with such provisions or this permit shall be deemed TRAILER uSE❑ GEOLOGY INSPECTION ElNo Spec Knowl ❑ ( revoked OCCUMNCY INSPECTION[$ Panic Devices ❑ � LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter SAFETYPERMMEI ILISTREMSSELOWI f I 9(commencing with Section 7000)of Division 3 of the Business, ,. OF EXITS and Professions Code and my license Is In full force and effect o CH9 PARKING REO D PROVIDED i License Number Lic Class G('G.h l� � cw�lirv�-ye SPACES ( I 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 ( acting in my professional capacity(Section 7051 Business SIZE OF NO OF INSPECTOR e and Professions Code) EXISTING BLDG STIES SIGNATURE. Lia or Reg. No Date PRE'JEW USE OF OUILDING FINAL APPROVAL 1—e"2 a2 HOME OWNER-BUILDER DECLARATION NO OF EXISTING BU -DINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 70315 Business and ( Profession.; Code) NO PARKING ❑ 1 as owner of the property will do the work and the SPACES PROVIDE. structure is not Intended or offered for sale(Section 7044 3 PROPOSED USE OF BUILDING Business and Professions Code) I 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 OCG Lenders Name A NT(RiJI) TEL Ft tams (6w 3.9-101 Lender s Address A G I RKAS N Q[.S i.rw-ta+1aJ NAS C, ( I certify that I have read this application and state that the above information is correct I agree to comply with a0 County PER.n.FEE ordinances and State laws relating to budding construction and hereby authimm representatives of this County to enter upon ISSUANCE FEE tt the above-mentioned property for inspection purposes 1 TOTAL FES % /-4 0..' SEE REVERSE FOR EXPLANATORY LANGUAGE ! ) / i, Signature Of Permittee Date