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Home My Public Portal About5406 BALDWIN AVE_Miscellaneous__ i ,%k0kKERS'COIPENSATION DELL.\R.�CIO� C6 875 :11 84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDINGAND SAFETY DIVISION t insure. or a.certificate of aaorkers'Contnensation Insurance.or �*t� a certified copy thereof iSec. 3800. Lai).C.I. `- I =�I Poli^.)' No. _C onwan} — FOR APPLICANT TO SILL IN BUILDING O/ A � DDRES !� Certified cope is hereby furnished. BUILDING f LOCALITY 7 AO DRESS { Certified cops' Is tiled \vlth [Ile'.:ntlntt Uu[[din_ insrectic7n NEAREST LOCALITY department. I Temple City CROSS ST. Date .a Dnil':ant NEAREST :JISTRI,CT N GR P TY P= CESSED BY CROSS GA a /�j, D �t CON i CERTIFIC:_\TE OF E\ENIPTfO� PRc)\t '.tC'Ri�LRS LEGAL vJ` //rL/Y // C ONIPENS:\TION INSI R.a`,C!_ ESCPIPT:O.'J LOT NO. .BLOCK IMAM wiG ww Av No (cIRCL_) STATE MAJOR SECOND LOCAL 1 NO. OF -LOGE. (This section need not Ile tomnleted If the \work involved {-4AC' ON LOT VSE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ISI001 or less.) It USE OF I ! SIzz OF LOT I EXISTING SLOG. I certify that in the oerfonnams -1.:e .\,,s6: .'0- -vhich -Itis fkup�I.iLy - permit is issued. I ;hall not cmolev :tn\ ,e-sen '.n in,* manner CWNER so as Io hecome ;uhiect :o the `•aorke-s' 1-,^nrensa[ion !.;nes. Y+ MAIL ESS OCCUPaI\1C:' .;ROUP � - - ! Date ADDR :applican: -_ NOTICE To APPLICANT:-If. at:e- kine -.tis •--..:,i;::[[e X] D:T• ji3wNC 0CCUP�N- LO;+D 44 Exemotie 1. ou siu uici becom :,.Lige: he 11 r�er<' _ Comcens-,wrt nro%ision:'.1! :hr I_abl'r \ou :nasi rnr:h- i APD' iCA-1C -mac = rl.;;:: ith cemai. ,x itl: aleh iro\'isi .. hi cr lit ;hail he I _-AILS- -SE - G_o_Ca+ N9 _-7•1CN - No SCP.C. '<aC':ii. I deemed r. ,e i. - - ,ENSEDCONIR.\CTORS DECL:%R.AT10' occuPANCY IN SPECTIOtigg 3l'C CE`."C'� Ll, I I hereby ai'irm :hat l am licensed and,-ore\isions of Chaetc- - L— SAFETY -ER-AIT (LIST ITEMS SELON� Q � I comniencinc with Section -000) of Di\isicn : 1 the Busi- No. OF EXITS ness and P- lesions Code. and m': license is it,, 'ail (Otte- and Pl 1C r: PC.4 ES ?ACES REDO PR C'l iD E7 License �u:a er _. i_ic. Cass LIMITED TIME USE vCon[r:1Ct(`r- !''[;--- DATE once z To f I an) :..erupt ;iUt11 -h' :Il l'n]in- .eau ire:nen[C :is I am 7INSPEC70R'S I licensed arC111;CC: 07 :17"21StereC ^!essinlial enm[neer ;IZE OF i NC. C= SIGNATURE Z aC:ln'- :r[ 'n\ 1,rclt•'::iunal ... aril - EX!STIN, BOG. - IlteSi,,I1;1 i r'.\ie,tiiCn.l nd.:l. FINAL APPROVAL ^RECENT USE OF BUILDING 01a N1 R-I,1 ILDER DECLA!:.\110\ NO. OF EXISTING BUILDINGS ` (� ON LOT AND USE I hereby .1 iirm that 1 am exempt from rite Contractor s UV License La\\ for the f(Aio\\i[r_, reason I Section -'t:l.:. Biid- ness and P-ofessionsCode): No. PARKING ❑ I, as ?\vner of the property. Wil] do 'lie work- and the SPACES PROVIDED stnlcn[re is not intruded or offered for ;ale ISertion i 7044. liu:inr<sand Ptt0tC9511)IB('11de1. CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CI / U I hereb% affirm that there is a construction lendins a_-envy for the performance of the work- for \which this permit is =••a }.'•. issued (Ser. 30q-.Civ. C.). `-�! Lender's Name ! PROPOSED MAX. OCC. Lender's.-address PERMIT FEE 25.00 <'( I certify that 1 have read this appli,-ation and state [hat the t I above information is correct. I agree in comply with all C omil%, ISSUANCE FEE ordinances and State lase relating to buiidins construction, rc and hereby authorizer r sentatives of this Count), to enter TOTAL FEE 25.00 upon the:Ibove-m i e property for inspection purposes. I SEE RENTRSE FOR EXPLANATORY LANGUAGE i _Cj t''•I ignat re of Permittee Date c_ WORKERS COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING D / 1 ADDRESS !� /Y Certified copy is hereby furnished. BUILDING ADDRESS _ LOCALITY 0 Certified copy is filed with the county building inspection LOCALITY _ ; NEAREST department. t ) CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P C SSED BY CROSS ST. S - 1 �Q CONST_.l CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP GHW AV No. /y,—� (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLD S. (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 SIZE OF LOT EXISTING BLDG. Z� I certify that in the performance of the 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 OCCUPANCY GROUP r_ ADDRESS Date Applicant C'�� rEL. OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY No. °.; Exemption, you should become subject to the Workers' 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. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING SPACES REQ'D D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DAT E I am exempt from the licensing requirements as I am a FROM. TO. licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus-, EXISTING BLDG. STORIES GNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING /S Lic.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. 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 I 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 on the above-mentioned property for inspection purposes. -� SEE REVERSE FOR EXPLANATORY LANGUAGE Ot Signature of Permittee e WORKFAS COMPENSATION DECLARATION 76M444 CE 875 (280) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to se►f COUNTY OF IAS ANGELES BUILDING AND SAFETY DIVISION Insure or a certificate of Workers Compensation Insurance or "fl a certified copy thereof(Sec 3800 Lab C)- I Policy No Company F FOR APPLICANTTO FILL IN t BUILDING ADDRESS LDING /////I _/ Certified copy is hereby furnished � + pDDR LOCALITY A ❑ Certified copy is filed with the county building Inspection �� NEAREST department LOCALITY vF J _ CROSS ST .e z Date Applicant CROSS ST 1 ? � ' F DISTRICT 7/ NO �JGROUP ITYPE CONST PROCESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL s DESCRIPTION' LOTTNO « BLOCK tr , COMPENSATION INSURANCE ` L ' nOP �D �(c RCLE) _,STATE MAJOR SECOND LOCAL CL (This section need not be completed ifathe work involved TRACT NOW ONBLOT LDS tJ USE ZONE -S ECTAL CONDITIONS - O by the permit is for one hundred,dollars ($100) or less) ' 4 � USE OF �7 ' SIZE OF LOT EXISTING BLDG f l/r� n I cc I 'certify that in the/performance of the work for which this O permit is Issued I shall not employ`any person In any manner I '11<NERea, 1 e s� to o )— so as to become subject to lthe Workers Compensation Laws IL A OCCUPANCY GROUP W ADDRESS W �CII�I"�'� 1CL Date Applicant rn NOTICE TO APPLICANT If rafter making this Certificate of CITY O'A/le V `1 I . NO = ¢ OCCUPANT LOAD z Exemption you should become subject to the Workers + Compensation provisions of the Labor Code APPLICATION FOR EXIT HARDWARE p p _ you must forth + r , with comply with such provisions or this permif,shall be TRAILER USE GEOLOGY INSPECTION No Spec Knowl K❑ deemed revoked - , ❑ r LICENSED CONTRACTORS DECLARATIONPanic Devices OCCUPANCY INSPECTION F r v r I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ! (LIST ITEMS BELOW) ' NO OF EXITS 9 (commencing with Section 7000) of$Divislon 3 of the Busl 1 " ness and Professions Code and my license Is in full force and effectV F SPACES PARKING REO D PROVIDED - r f I s' License Number Lic Class M w 1 b LIMITED TIME USE Contractor" Date DATE DATE ❑ T _ FROM TO I am exempt from the licensing requirements as [am a licensed architect or a registered professional engineer SIZE OF No IOF IN PECTOR S acting in my professional capacity (Section 7051 Bus EXISTING BLDG STORIES IGNATURE mess and Professions Code SENT USE OF BUILDING FINAL APPROVAL !/ Llc or Re No x Date Reg 1 No of Exlsrl BUILDINGS IR HOME OWNER BUILDER DECLARATION i + + , � ON LOT AND USE l,hereby, affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Busl ness and Professions Code) NO PARKING B^ ^ ^ i 2 SPACES PROVIDED r 2 L 9 H ❑>I`i,as owner'of the property will do the work and thei Vrr u # „� structure is not intended or offered for sale (Section a • • 0 0 8 8 7044 Business and Professions Code) $ T " P.. b POSED USE OF BUILDINGv CONSTRUCTION LENDING AGENCY - I hereby affirm that there is a construction lending agency �� a RS d027-85(� r for the performance of the work for which this permit is t - issued (Sec 3097 Civ C Lender s Name PROPOSED MAX OCC « r 1 ^ � F J y 1 Lender ss Addressl M {PERMIT FEE a I certify that I have read this application and state that the a r above infoirmatAn is correct` I agree to comply with all County IISSUANCE'FEE 1 ya ordinance a tate laws relating to building construction {J m + r and hireb u oriz representatives of this County to Venter }` ITOTAL FEE w upon the a me oned r perty for mspecpjrlp�� ttt ses / E REVERSE FOR EXPLANATORY LANGUAGE ry s T 4 I/ 4",00, / D Igna ure of D Perm ee + ate Z 1