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Home My Public Portal About5000 ENCINITA AVE_Miscellaneous__ ` WORKERS'COMPENSATION DECLARATION 768444_ MISCELLANEOUS A P P L I C A T I O N LE 875(11 84) I hereby affirm that I have a certificate of consent tself COUNTY OF LOS A1, ELsES EUILDING AND SAFETY DIVISION insure, or`a certificate of Workers'Compensation Insurance, e,or . ,(J a certified copy thereof(Sec 3800,Lab C) Policy No61931-1-3company ! (MrE CompepsWwsi Tosumixt FOR APPLICANT TO FILL IN ,JJ ADDRESS 5000 �t1 C1✓1 1�a -R(/eRU IPiyt_elSG �Ci Ci Certified copy is hereby furnished BUILDING f AU(?AuP, -rer), le C� XX ADDRESS X6001) (�1�11 LocALlrr ElCertified copy is filed with the county, uiling inspection LOCALITY NEARESCROSS Sr T w P� departm nt ` 3M Bn NEAREST DISTRICT O GROUP TYPE P CC ESSED BY CROSS ST Date Applicant ko we(L A-2-as 1 �D�j CONST i/ d yi CERTIFICATE OF EXEMPTION OM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO 5 BLOCK MAP NO OF BLDGS ;�J LHIGHWAY Nql (CIRCLE) STATE MAJOR SECOND LOCAL + D " (This section need not be completed if the work involved TRACT 10 9 NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) USE OF r!" h c11Ke SIZE OF LOT v (0,000 EXISTING BLDGQCeSSJO- a I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manned OWNER of buildingS6r =' so as to become subject to the Workers' Compensation Laws MAILOCCUPANCY GROUP o ADOR Ess 913, Date Applicant �x ,p iv NOTICE TO APPLICANT If, after making this Certificate of CITY ffionAere plr{( CA NOL )13—.264-70q9 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 OCCUPANCY INSPECTION [� Panic Devices LICENSED CONTRACTORS DECLARATION 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 ani r U / effect AXE Name of business �eQ V NS �//C. PARKING SPACES REQ D PROVIDED License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE FROM TO ElI am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF LLllr�� NO OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG T,QZSQ tiJ STORIES S'GN mess and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING ')•nlll. �'y j Lic or Reg No Date �� —___ p �' + HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS I 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 DI, as owner of the property, will do the work and the SPACES PROVIDED I G structure is not intended or offered for sale (Section 7044,Business and Professions Code) PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency O er 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 25 , on above information is correct 1 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 pve-men o property for inspection purposes XX XX 7 r SEE REVERSE FOR EXPLANATORY LANGUAGE B to SIR lure of Pennrtte Date WOR�C�`S'COMPENSATION DECLARATION CE 875 `(1 1 843 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) BUILDNG Policy No Company FOR APPLICANT TO FI LL IN ADDRESS � p � ADDRESS v T/�!�/% Certified copy is hereby furnished BUILDING 500 ENC IN ITA AVE LOCALITY ADDRESS 0 Certified copy is filed with the county building inspection LOCALITY TEMPLE CITY CA NEAREST (�department Date Applicant NEAREST DISTRICT N GUP ITYPE / PROCE E CROSS ST I,(!f, CONST V CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO /Sect.CJ BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SE CO LOCAL NO OF BLDGS (This section need not be completed if the work involved TRACT 098 NOW ON LOT USZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) p USE OF SIZE OF LOT 10, 068 EXISTING BLDG I certify that in the performance of the work for which thisA:�:A o permit is issued, I shall not employ any person in any manner OWNEROF L E DON S. CHIN S-D so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP o ADDRESS P.O.Box 1216 C~.7 Date Applicant TL LUNOTICE TO APPLICANT If, after making this Certificate of clrr Rosemead, CA NE 7o o y9 OCCUPANT LOAD z Exemption, you should become subject to the Workers' APPLICATION FON 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 PERMX 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 R6p'D � PROVID HD SPACES License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE FROM TO 0 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 SIGNATURE mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL Lic or Reg No Date I 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 A # 0 0 0 0 8,8 structure is not intended or offered for sale (Section Y 7044,Business and Professions Code) � o D o 0 0 0 o z CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING/__1&_,0 / z _i I hereby affirm that there is a construction lending agency 1,2 2`8 8 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 d 0 I certify that I h e read this application and state that the PERMIT FEE above informati0 is orrect I fflawith all County ISSUANCE FEE ordinances and tat laws reg construction, d hereby aut e rwenCounty to enter TOTAL FEE on the abov e tion protio�pUrposes OV SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date I WORKERS (_UMMNJAIIUN LCI.-LAKt111V1Y 20-0063OPW12/90 !rX L+G.LL.H1V.C.V V l-1 I—X—Ll`.Ci 1 1v1 % I hereby affirm that I have. a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 'rinsure, or a certificate of Workers'Compensation Insurance, or , a certified copy thereof (Set 3800, Lab C), - - Policy NO. QL--n ny 5;fAte&ffl ¢»3A�1Q)7.�Lfl� FOR APPLICANT TO FILL IN BUILDING Qj —'— ' BUILDING ADDRESS ADDRESS I ❑ Certified copy is hereby furnished g Soot/ MQ Qr LOCALITY ❑ Certified copy is filed with the county building inspection CITY ZIP NEAREST department IC CROSS ST Date Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY CONST Q- CERTIFICATE OF EXEMPTION FROM WORKERS TRACT BLOCK LOT NO O COMPENSATION INSURANCE MAP HIGHWAY Q NO (CIRCLE) STATE MAJOR SECOND LOCAL by is section need not be completed l s ( work Involved ASSESSOR MAP BOOK PAGE PARCEL t1' � by the permit is for one hundred dollars ($100) or less) usE zoNE SPECIAL CONDITIONS y TEL NO L I certify that to the performance of the work for which this X )Mr orf er Q permit is issued I shall not employ any person In any manner W so as to become subject to the Workers Compensation Laws ADDRESS 33 �� OCCUPANCY GROUP Z Date Applicant CITY ZIP NOTICE TO APPLICANT If after making this Certificate ODS 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❑ No Spec Knowl ❑ ' revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Ej Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) a 9(commencing with Section 7000)of Division 3 of the BusinessNO OF EXITS and Professions Code and my license is in full force and effect ame ot Business �l � PARKING REO'D I PROVIDED I I License Number Lie Class SPACES E_JJ J Contractor Date G JL LIMITED TIME USE i ❑ I am exempt from the licensing requirements as I am a DATE DATE FROM To licensed architect or a registered professional engineer acting in my professional capacity (Section 7051, Business SIZE OF NO OF INSPECTOR'S I ` and Professions Code) EXISTING BLDG STORIES SIGNATURE. Lic or Reg No - Date PRESENT USE OF BUILDING FINAL APPROVAL 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 70315 Business and Professions Code) NO PARKING i ❑ I, as owner of the property will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,1 PROPOSED USE OF BUILDING Business and Professions Code) CONSTRUCTION LENDING AGENCY 2 I hereby affirm that there is a construction lending agenc) for the performance of the work for which this permit is issued (Sec 3097, Civ C) PROPOSED MAX OCC, Lender's Name APPLICANT(MAn") TEL NO o 4.06-0&W-53 51 Lender's Address AD Ess Icertify that I have read this application and state that the 1-119 V)604A JA& 0 , above information is correct I agree to comply with all County PERMIT FEE I ordinances and State laws relating to building construction,and j hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes it TOTAL FEE xS03e� -771 el 5t)S Rod!:)qlie z 10 if 0A SEE REVERSE FOR EXPLANATORY LANGUAGE f Signature of Permittee Date J