HomeMy Public PortalAbout9527 BLACKLEY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
• CE 875
I hereby affirm that I have a certificate of consent to sett' 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 0(
Certified copy is hereby furnished. BUILDING y
ADDRESS / LOCALITY
Certified•copy is filed with the county building inspection LOCALITY NEAREST
department CROSS ST
Date Applicant NEAREST DISTRICT NO. GROUP ITYP E: 'PROCESSED BY
CROSS ST. •D Q A �' CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a /s
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
rvo. (cIR 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 ($100) or less.)
USE OF
SIZE OF LOT EXISTING BLDG. a
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 CC-m� LL,,41Q,_ o
so as to become subject to the Workers' Compensation Laws. MAIL _ OCCUPANCY GROUP 3 Ce
' ADDRESS S� �L,A�, Lr �� I C~1
Date Applicant E3
TEL OCCUPANT LOAD D
NOTICE TO APPLICANT If, after making this Certificate of CITY ' T
Exemption, you should become -subject to the Workers' APPLICA ION 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. Know].
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. G��fi' Gt2�l� PARKING
SPACES REQ'D PROVIDED
License Number Lic Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM TO•
F1 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- EXISTING BLDG. STORIES SIG NASIJRE
U
iness and Professions Code). FINAL APPROVAL �j / //
PRESENT SE OF BUILDING `
Llc.or Reg.No. Date �•
<L... �G• ms`s_
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE 8
I hereby affirm that I am exempt from the Contractor's 3307 - X13°
License Law for the following reason (Section 7031.5, Busi
ness and Professions Code) NO. PARKING ITEMS
n
I, as owner of the property, will do the work and the SPACES PROVIDED I It
structure is not intended or offered for sale (Section y' ✓�5 '- gip; �: . *' .TUTL.='=� —�
7044,Business and Professions Code).
PROPOSED USE OF BUILDING - + a•"""'_ ,J of "S - "'•'�� E �,y+y'.i 1gl r
CONSTRUCTION LENDING AGENCY -FIFi'
I hereby affirm that there is a construction lending agency - C ]I`; �' i �{�'°'Y.•
for the performance of the work for which this permit is
issued(See 3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address / 63,64 1 1 AM 9'.,14
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 7
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned property for inspection purposes.
��-6 —9� SEE REVERSE FOR EXPLANATORY LANGUAGE -
l�
Signature of Permittee Date
t '
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MISCELLANEOUS PERMIT "
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS MP 0508 971201000.3
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
Y PHONE: (818) 285-0488 EXT:
-tEGAL D: NO.-OF CONST NEW 'BUILDING ADDRESS:
ON FILE SQ. FT STORIES TYPE OCCUP GROUP 19527 BLACKLEY ST
STRUCTURE: 1 VN R3 TEMP CA 917803143
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
859,0-005-012 EXIST BLDG USE: - - THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY
EXIST OCC GRP: USE ZONE:
TENANT: ED ON: PROCESSED BY: EXPIRES 0
NOW OWTUrT VALUATION: 12/01'/97 UT 12/01/98
0
OWNER: TEL. NO: FINAL DATE FINAL BY ODE:
ZHONG SHANG YOU (310)-275-8887- L S
9527 BLACKLEY ST �Z'�a`q'
TEMP 917803143 DESCRIPTION OF WOR
CONVERT GARAGE BACK TO INTENDED USE
OCCUP LOAD EXIST: .
APPLICANT: L. NO: OCCUP LOAD NEW:
SAME AS OWNER
PARKING SPACES REQUIRED:. SPECIAL ONDITIONS:
PARKING'SPACES��� C •
EXIT HARDWARE:
CONTRACTOR: TEL. NO: j I�� ® LIMITED TIME USE
SAME AS OWNER - NBR OF EX•IiTS: FROM TO
LIC. NO i
FEES' AlID /B� APPROVALS DATE INSPECTOR SIGNATURE
FEE DESCRIPTsI0N ' QUANTITY: UOM: AMOUNT:
ARCHITECT ENGINEER: . NO:, d 1 61 �� � � R S
q,0AjJPERMIT ISSUANCE a� 27.75
LIC. NO: 01 R%M OCC/USE, IINSPECT 145.95 SAFET( PERMIT
TOTAL,FEESm it 173.70
TEMP.?S UCT. APPROVED
_ L
MA. NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: �8� ® K� TEMP. STRUCT. REMOVED
ruDNO. OF FAMILIES: DWELL ING.UNITS:. ." STAT "CLASTF
NO
co
SC IN HAZARDOUS { _ ,
AIR QUALITY: 1000 FEET MATERIALS" �� Q
NO NO NO
REQUIRED TO BACK FROM EXIST
SET BACK YARD: HWY: PROP LINE: WIDTH: b
FRONT PL-
SIDE PL- �( f/pae
i
REPORT ID: DPR267 ROUTE TO: BS0508
;r ,