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Home My Public Portal About5004 ENCINITA AVE_Miscellaneous__ WL'1RKERS'COMPENSATION DECLARATION CE 875 (11 84) MISCELLANEOUS APPLICATION �7 CE 875 I laffirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insureure,, o 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 r ADDRESS Certified copy is hereby furnished BUILDING Q G {� LOCALITY ADDRESS /+� D Certified copy is filed with the county building inspection LOCALITY NEAREST department CROSS ST Date Applicant NEAREST DISTRICT NO G-� YZT—PW71�—f CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP G.WAY NO / 2,ep (CIRCLE) 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 //n7�/A'1 i d I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG I permit is issued, I shall not employ any person in any manner OWNERo so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP 1 0 ADDRESS D✓� U Date Applicant NOTICE TO APPLICANT If, after making this Certificate of CITY NOL OCCUPANT LOAD o_ Exemption, you should become subject to the Workers' APPLIC TION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth- wlth Comply with such provisions oI 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 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 ,� PARKING SPACES REQ D PROVIDED License Number Lic Class C LIMITED TIME USE Contractor Date L DATE DATE I am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer SIZE OF NO OF INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES S GNATURE mess and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING �j 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- � 11ij,�i, ness and Professions Code) NO PARKING SPACES PROVIDED I, as owner of the property, will do the work and the ♦ i I j E rG structure is not intended or offered for sale (Section 7044,Business and Professions Code) !I!1 til 80 . 50 I PROPOSED USE OF BUILDING 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 OCC �Ii — -; Lender's Address PERMIT FEE I certify that I have read this application and state that the — above information is correct I agree to comply with all County ISSUANCE FEE V ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon the ove-mentioA property for inspection purposes �ZJ SEE REVERSE FOR EXPLANATORY LANGUAGE Signat re Xf Permittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11 84) MISCELLANEOUS APPLICATION {� CE 875 LI 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 Certified copy is hereby furnished ADDR SS M I U LOCALITY ADDRESS 1/� NG ElCertified copy is filed with the county building inspection LOCALITY NEAREST department CROSS ST Date Applicant NEAREST � �j�- DISTRICT NO GROUP CONS ITYPEE SS ED BY ✓ CROSS ST 'V� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO (CIRCLE) 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 Y I certify that in the performance of the work for which this o_ C:) permit is issued, I shall not employ any person in any manner d OWNER so as to become subject to the Workers' Compensation Laws MAIL '-7 OCCUPANCY GROUP _ o ADDRES ,,/� I I�� ~ Date Applicant !, 1 TEL g O2 NOTICE TO APPLICANT If, after making this Certificate of CITY ( yh�Y0 No P) 0�6 J 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 ID deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions o£Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect PARKING REQ'D D PROVIDED SPACES 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- - EXISTING BLDG STORIES SI NATURE mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL � A� Lrc or Reg No Date �Y HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS NO F E I I hereby affirm that I am exempt from the Contractor's ON LOT AND USE Q �I License Law for the following reason (Section 7031 5, Busi- ness usi `�7c/4� ness and Professions Code) NO PARKING 171 h� I, as owner of the property, will do the work and the SPACES PROVIDED 1 AM 9e30 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 PERMIT FEE I certify that I have read this application and state that the above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and here y authorize representatives of this County to enter TOTAL FEE upon the above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE i -I/ L Sign re of hr :iltee bate WORKERS'COMPENSATION DECLARATION CE 8454(1184) 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 TREMAN1S Elm FOR APPLICANT TO FILL IN BUILDING FO ��7 ADDRESS Cert iiI e�"coBUS ere ysfurnlshed BUILDING ADDRESS 5004 ENCINITA AVE. TEMPLE CITY LOCALITY FICertified copy is filed with the county building inspection LOCALITY NEAREST department CROSS ST Date Applicant [TY E CNEAREST ROSS ST BEIWEEN LA ROSA & SERENO DR. DISTRICT NO GROUP CO ST pROCE SSED BY CERTIFICATE OF,EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SECOND LOCAL NO OF BLDGS ' (This section need not be completed if the work involved TRACT NOW ON LOTUSE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars,($100) or less) �T�1 USE OF I�Ir SIZE OF LOT 4975.5 SQ 1'1 EXISTI N PHCD T(X� AND" > 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 y so as to become subject to the Workers' Compensation Laws JANE F[JNG MAIL OCCUPANCY GROUP o Date Applicant ADDRESS 107 N. MUSCATELS AVE. SAN GABRI SAN GABRIEL N0 (818) 287-0534 OCCUPANT LOAD W NOTICE TO APPLICANT If, after making this Certificate of CITY No vi Exemption, you should become subject to the Workers' z 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 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 and U effect fA ft//��L WA//^'e255 I PARKING REQ D PROVIDED License Number Lie Class SPACES LIMITED TIME USE Contractor Date DATE DATE ROM TO I am exempt from the licensing requirements as I am a P licensed architect or a registered professional engineer SIZE-OF NO -OF 1INSPECTo •s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG 4975.5 SQ Z 1 STORIES SIG NAT R / iness and Professions Code) PRESENT USE OF BUILDING 100% FINAL APPROVAL ✓� Lie or Reg No Date HOME OWNER-BUILDER DECLARATION - NO of EXISTING BUILDINGS 1 17� ON LOT AND USE I , I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busi- ness usi ness and Professions Code) No PARKING SPACES PROVIDED 0 I, as owner of the property, will do the work and the 4 _.�_,J Z � t structure is not intended or offered for sale (Section 7044,Business and Professions Code) ,., PROPOSED USE of BUILDING OFFICE AND CONSTRUCTION LENDING AGENCY , I I hereby affirm that there is a construction lending agency WAREHOUSE I ✓l 8 for the performance of the work for which this permit is 111 issued(Sec 3097,Civ C) Lender's Name 15 PROPOSED MAX OCC Lender's Address PERMIT FEE - I certify thht I have read thi/rep� licationand state that the above information is correct I to comply with all County ISSUANCE FEE ordinances and Statelaws rg to ding construction, and hereby author repres ntatrves of is County to enter TOTAL FEE upon the abo d ope r inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 11/13/89 gna re f P rmitte Date t WORKERS'COMPENSATION DECLARATION . 76 CF 8754(11-84) M ISCELLANEOUIS= APPLICATION 1 hereby affirm that I have a certificate of consent 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 AD OR ESS��DO Certified copy is hereby furnished. I VVILDING ,/ D RESS XX. Y LOCALITY Certified copy is filed with the county building inspecti LOCALITYNEAREST department. C CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P aCESSED BY CROSS ST. -50� CONSY. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. F SLOGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. d I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any mannLD e '.X OWNER of building `� so as to become subject to the Workers' Compensation Law . MAIL OCCUPANCY GROUP � ADDRESS 6�v e Si.. //� G7 12:1 Date Applicant 1J NOTICE TO APPLICANT: If, after making this Certificate of CITY, No ' OCCUPANT LOAD �S o z Exemption, you should become subject to the Workers' APPLICATION F R EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- E]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 Bus' SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code, and my license is in full force a X effect. SIrie of business PARKING SPACES REO'D PROVIDED License Number Lic. Class C IC g� ;Aft--, �� LIMITED TIME USE Contractor Date I DATE DATE EJI am exempt from the licensing requirements as I am a FR�'M: TO: licensed architect or a registered professional engineer SIZE OF F-.06 o. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL Lie.or Reg.No. Date PRESENT USE OF BUILDING HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS JV ON LOT AND USE l f" I hereby affirm that I am exempt from the Contractor's ►�1 License Law for the following reason (Section 7031.5, Busi- ness usi ,I { Hess and Professions Code): NO. PARKING ti=: _= El1, 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). "..�.,. (:` T CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING { I: -.. 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 1 certify that I have read this application and state that the PERMIT FEE 25 . 00 above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby auth ize represen�tives of this County o enter TOTAL FEE 25 . 00 upon the e- n ed erty for inspec'on p os l [ \ ,c SEE REVERSE FOR EXPLANATORY LANGUAGE t XX\� XX .i aSignature of Permittee Date