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WORKEgS'COMPENSATION DECLARATION CE 87 5((11-84) M I SC E L LA N E®U S APPLICATION
I herejio 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 I N BUILDING i/
ADDRESS
Certified copy is hereby furnished. BUILDING /V LOCALITY
ADDRESS
FCertified copy is filed with the county building inspection LOCALITY ,(� NEAREST
department.
CROSS ST.
Date Applicant NEAREST I DISTRICT NO. GUP TYPE PROCtE SED BY
CROSS ST. /�� -7-, CON 3 /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ` v�
COMPENSATION INSURANCE D CRIP ION LOT NOZ BLOCK MAP' HIGHWAY \\
NO. (CIRCLE) STATE MAJOR SECP D LOCAL
(This section need not be completed if the work involved TRACT NOW ON LOT S USE ZONE SPECIAL CONDITIONS //
by the permit is for one hundred dollars ($100) or less.) f usE of I
I certify that in the performance of the work for which this CD
SIZE OF LOT / EXISTING BLDG. CD
0
permit is issued,I shall not employ any person in any manner OWNER y
so as to become subject to the Workers' Compensation.Laws. MAIL J OCCUPANCY GROUP �J o
ADDRESS -�/ F
-Date Applicant TEL. (� / 7s W
NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. /� / OCCUPANT LOAD 0-
Exemption,
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.
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 REQ'D D PROVIDED D
SPACES
License Number Lie. Class - `J LIMITED TIME USE
Contractor Date I DATE DATE
FROM: TO:
❑ I am exempt from the Iicensing requirements as I am a
licensed architect or a registered professional engineer SIZE OFNO. OF J INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. U STORIES / SIG ATURE
iness and Professions Code). FINAL APPROVALG�iL IK�
PRESENT USE OF BUILDING / q
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- �2 7 8 8,7 A
ness and Professions Code): NO. PARKING
❑ I, as owner of the property, will do the work and the SPACES PROVIDED 4. 0 s o"• 30
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
I - 8,0,5,0
5,0
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING • a o 8 0,5 0 v
I hereby affirm that there is a construction lending agency 0 9J o t 8 7
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 h
(/
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 ) S D
or
a d State laws relat" to building construction,
and I b author" /repre a " es of this County to enter TOTAL FEE /J
up above 4one pro rty fo 'Apection purposes.
11 '� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per " ee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MISCELLANEOUS PERMIT
DEPARTMENT OF PUBLIC WORKS - 9701 LAS TUNAS MP 0508 1106070002
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEG ID:
FILE I NO. OF CONST NEW I BUILDING ADDRESS:
ON
SQ. FT STORIES TYPE OCCUP GROUPI 4838 GOLDEN WEST AV 1
ISTRUCTURE: 1 V-B U I TEMP CA 917803935 1
(ASSESSOR INFORMATION NUMBER: I INEAREST CROSS STREET: LOWER AZUSA
18589-020-025 (EXIST BLDG USE: I THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY I
I 1EXIST OCC GRP: USE ZONE:
(TENANT: I (ISSUED ON: PROCESSED BY: 1
IBLDGS. NOW ON LOT: VALUATION: 106/07/11 SR 1
1,000
(OWNER: TEL. NO: I 1FIPTAL FyTE _ FINAL B CODE: 1
ICHEUK NG AND MIA FANG WU (626) 319-8587- ILIST ITEMS:
14838 GOLDEN WEST AV I I1
ITEMP 917803935 1D CRIPTION OF WORK
I IRE-CONVERT A 2-CAR ATTACHED GE BACK TO ITS INTENDED USE I
I IOCCUP LOAD EXIST: 1AND USE AS A 2-CAR GARAGE 1
1APPLICANT: TEL. NO: IOCCUP LOAD NEW:
ISAME AS OWNER - I 1 I
I IPARKING SPACES REQUIRED: ISPECI,AL CONDITIONS: 1
I IPARKING SPACES PROVIDED:
I I
I IEXIT HARDWARE: 1 I
ICONTRACTOR: TEL. NO: I I LIMITED TIME USE
ISAME AS OWNER - INBR OF EXITS:
FROM TO
LIC. NO I I
FEES PAID 1 I
(APPROVALS DATE INSPECTOR SIGNATURE
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 I I
(ARCHITECT OR ENGINEER: TEL. NO: I ITRAILER USE
1 - IOA PERMIT ISSUANCE 27.80 1 I I I
1 LIC. NO: 101 R/M OCC/USE INSPECT 146.00 ISAFETY PERMIT I 1
I TOTAL FEES 173.80 1 I I
I (TEMP. STRUCT. APPROVED I I
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:( (TEMP. STRUCT. REMOVED I I
I 1 I
1144H269 I I 1 I I
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 1 I I I
1 NO I I
1 SCHOOL WITHIN HAZARDOUS I 1
1AIR QUALITY: 1000 FEET MATERIALS I
1 NO NO NO
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I
I I I I I
1 I I I I I
IREPORT ID: DPR267 ROUTE TO: BS0508
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