HomeMy Public PortalAbout9700 LAS TUNAS DR_Miscellaneous__ WIIZRKERS'COMPENSATION DECLARATION 761 444 A p>sp ®� APPLICATION,�Ics /'� di T I®p1
C 875 (2-80) A l\9 P � l� C A tl N
I hereby affirm that I have a certificate of consent to self COUNTY.®F LOS ANGELES BUILDING AND SAFETY DIVISION
insurr or a certificate of Workers'Compensation Insurance,or
a certl ed copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS
floe E., �o
Certified copy is hereby furnished. BADDRESS 9700 Las Tunas DrLOCALITY �"
Er C_
•
Certified copy is filed with the county building inspection I NEAREST
department. LOCALITY Temple MCalif. 91780 CROSS ST:
Date Applicant NEAREST I(� DISTRICT NO. P. TYP PR ESSED BY
CROSS ST. Kauffman '� • CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' - I LEGAL v
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP t GHWAY HI
p4 OG STATE MAJOR SECOND LOCAL
(CIRCLE)
}
NO.
NO. OF LOGS. LI
(•1.1115 section need not be completed if the work involved TR CT ✓\ /V_ NOW ON LOT USE ZONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars ($100) or less.) I USE OF ^/— U
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this i
permit is issued, I shall not employ any person in any manner OWNER Austin Hall I .
so as to become subject to the Workers' Compensation Laws. mdlL OCCUPANCY GROUPS U
ADDRESS 9709 Las Tunas Dr. W
Date Applicant L'
TEL.
NOTICE TO.APPLICANT: If, after making this Certificate of CITY Temple Cit No• 487-048 OCCUPANT LOAD z
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❑ I No Spec. Knowl. ❑
deemed revoked. Panic Devices ElLICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT I 1 (LIST ITEMS BELOW) NO. OF EXITS
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:
SPACES REQ'D E:= PROVIDED D
License Number Lic.Class
' LIMITED TIME USE
Contractor Date I GATE GATE
❑ I am - a I FROM: 1 TO: .
exempt from the licensing requirements as I am
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
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING ! �,-.�, ^ � �_f ` �...•
Lic.or—Reg.No. Date f
I '
HOME OWNER-BUILDER DECLARATION Nd.OF EXISTING BUILDINcs
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 and Professions Code): No. PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the i 1 ,2 8. 1 A
structure is not intended or offered for sale (Section
7044,Business and Professions Code). .o a o o 88
PROPOSED-USE OF BUILDING
CONSTRUCTION LENDING AGENCY A i o 0 0 0 0 0 o In
I hereby affirm that there is a construction lending agency I �/
for the performance of the work for which this permit isi 9.2 2—8'1-
issued(Sec.3097,Civ.C.). af
Lender's Name
PR POSED MAX. OCC. i
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 hereby authorize resentatives of this County to enter TOTAL FEE
u t e above- a one pr erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ig f Per t Date 1
I
I
WORKERS'COMPENSATION DECLARATION I
CE 875(2-80) W C C C A tl E OV C APPLICATION®PLICPTB®A
I her9by 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 cefi f)ed copy thereof(Sec.3800,Lab.C.)
Policy No. Company I FOR APPLICANT TO FILL IN ADDRESS /�77
❑ Certified copy is hereby furnished. BUILDING QV a�
LOCALITY
ADDRESS 9700 E. Las Tunas Dr.
F-1Certifiedcopy is filed with the county building inspection NEAREST
department. i LOCALITY Temple City, CA 91780 cRoss ST.
Date Applicant NEAREST DISTRICT NO. GR TY E PROC SSED*BY
CROSS ST. Kaufmann CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL s,Glee ��
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK
MAP HIGHWAY
NO. OF BLDGS. NO. � (CIRCLE)
STATE MAJOR SECOND LOCAL
a.
(This section need not be completed if the 'work involved I TRACT NOW ON LOT USE ZONE 75EcIAL.CONDITIONS
E
by.the permit is for one hundred doljars ($100) or less.) , USE of U
SIZE OF LOT EXISTING BLDG. �+��
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 Hall O
so as to become subject to the Workers' Compensation Laws. Austin S. I OCCUPANCY GROUP
MAIL
ADDRESS 2975 Wilshire Blvd. Suite 1 I W
Date Applicant U
NOTICE TO APPLICANT: If, after makingthis Certificate of I CITY Diol OCCUPANT LOAD
Los Angeles 487-4848 _
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 I TRAILER USE 0 GEOLOGY INSPECTION No Spec. Knowl. ❑
deemed revoked. i Panic Devices ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter I SAFETY PERMIT ❑ (LIST ITEMS BELOW) I NO. OF EXITS ❑
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and I Medical Profession PI .
effect. S RKINGREO'D
O PROVIDED O
S ACES
License Number Lic.Class I I LIMITED TIME USE
Contractor Date ��� I DATE DATE
el El F' OM TO:
I am exempt from the licensing requirements as I am a ( L,
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my .professional capacity (Section 7051, Bus- I EXISTING BLDG. STORIES i SIGNATURE
iness and Professions Code). ANAL APPROVAL
PRESENT USE OF BUILDING i ••t_k-e
Lic.or Reg.No. Date I Medical I �/67 � / 1
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 1 .5 0 3 A
SPACES PROVIDED i
❑ I, as owner of the property, will do the work and the I # e�o o 0 8 8
I
structure is not intended or offered for sale (Section i . ' � •
7044, Business and Professions Code). I PROPOSED USE OF BUILDING I o 0,0 0.0 a o z
CONSTRUCTION LENDING AGENCY Q 0.9-8 1
I hereby affirm that there is a construction lending agency '
for the performance of the work for which this permit is I
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC-
Lender's Addres s
CC.Lender'sAddress I PERMIT FEE
I certify that I have read this application and state that the ISSUANCE FEE
above information is correct.I agree to comply with all County I
ordinances and State laws relating to building construction, TOTAL FEE
an hereby authorize representatives this County to enter
the above- ned p rty o inspection purposes. I�SEE REVERSE FOIR EXPLANATORY LANGUAGE Cry
dr QL
Signature of Permittee 1 Date/1
WORKERS'COMPENSATION DECLARATION CE 875 MISCELLANEOUS' APPLICATION
CE 875 (2-801
I hereby •affirm that i have a certificate of consent nt seer' 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 Ano ESS.
❑ Certified.copy is hereby furnished. wUILDIN 9DDRESS 700 LOCALITY
❑ Certified copy is-filed with the county building inspectionNEAREST
department. ' L-OCALITY " Temple Cl ty, CA 91780
CROSS ST.
Pate Applicant. EAREST t. r D1ISTRICT NO. P TY PROCESSED BY
CROSS ST. I U CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J �y
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP �{/� cIG c�eY }
( 1 STATE MAJOR SECOND LOCAL d
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT �� NOW ON LOT USE.ZONE SPECIAL CONDITIONS Q
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT.. EXISTING BLDG.• �'
I certify that in 'the performance of the work for which this
permit is issued, I shall not employ any person in any manner � dWNER Austin 1 I O
so as to become subject to the Workers'Compensation Laws. 1 MAIL r' OCCUPANCY GROUP UJ
ADDRESS 2975 6dfi•l sk re ,B.l vd. , Suite- 1a-
Date Applicant li i Z
TEL' OCCUPANT LOAD,
' NOTICE TO APPLICANT: If, after making this Certificate of L�.CITY Los Angel es••90b67ND. 48.7-4$48 '; —
Exemption, 'you. should become'subject to the Workers' APPLICATION FOR EXIT HARDWARE: '
Co.mpensatioh provisions of the Labor Code, you must forth- �;
with comply with such provisions or, this permit, shall be •i TRAILER USE GEOLOGINSP E.CTION
deemed revgked. ❑ [_Y IVO Spec. KnOWI. ❑
Panic Devices ❑ '
LICENSED CONTRACTORS DECLARATION occurwncY'INSPECTIon❑ 1
I hereby affirm that I am Iicensed'under-provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS 6EL6W) ) NO. OF EXITS
'9 (commencing with•Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my.license is in full force,and
PARKING
effect.
SPACES REq'D E= PROVIDED
License Number Lic.Cldss
LIMITED TIME USE
Contractor Date o AT a DAT e
❑
I am exem : .. - '
pt from.the licensing requirelrierits as I am a FOM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting In my professional capacity•(Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code).
FINAL APPROVAL _
<•'PRESENT USE OF BUILDING me.d •c l offfc6. I I® �+ ��r �'�'I•-�..�,1
Lic:or Reg.No. Date
H O ME•OWNER-BUILDER DECLARATION No.of AND UNG BUILDi1VG$ F
• ON LOT AND USE '
� 1 .43QA."
I hereby affirm that- I am exempt from the Contractor's'
License Law for the-following reason (Section 7031.5, .Susi- # o 0 0 0 $8
ness and Professions Code): NO. PARKING
SPACES PROVIDED
I, as owner of.the "operty,.will do the-work•andthe .;0 0 0 0 0 0 0
structure is not intended or.offered for sale (Section _ '
0 8,06
1'
7044,Business and Professions Code). � ••'PROPosED USE OF BUILDING '
medi
cal
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 Namej
PROPOSED MAX. OCC. fi ,
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 lating to building construction,
and hereby authorize epr entativ of.this County to enter TOTAL FEE•
upon-the above-menti ne proper for insp tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE '
�
C ., '
Signature of Permittee Date +4
WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APrL0CATIO1\!
I hereby affirm that I have a certificate of coInsura c 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 /J�7
ADDRESS r,�V4sy��e �
❑ Certified copy is hereby furnished. BUILDING LOCALITY
ADDRESS w '
❑ Certified copy is filed with the county building inspection NEAREST
department. LOCALITY �• CROSS ST.
l
Date Applicant NEAREST DISTRICT NO, GR P TYP PRO ESSED
CROSS ST.. t kp'1' , ,rt/�� ..) C
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �V .1
D
COMPENSATION INSURANCE ASCRIPTION 'LOT NO. BLOCK ' MAP GHWAY
No.I MA
�Ov / (CIRCLE) STATE MAJOR SECOND LOCAL CL
NO. OF BLDGS. I
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS Q
/
by the permit is for one hundred dollars ($10.0) or less.) USE OF U
SIZE OF LOT EXISTING BLDG. '
I certify that in the performance of the work for which this 0
permit IS issued, I shall not employ any person in any fnanner OWNER QN
so as4to *ecomeubject to th Work rs' Compensation Laws. MAIL 1 OCCUPANCY GROUPADDRESS /DateApplicant aNNOTLICANT: If, after making this ertificate of CITY NOL 't �aLt 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 provisigns Or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION
deemed revoked. NO Spec. Know(. ❑
� ' P8111C Devices
❑ '
LICENSED CONTRACTORS DECLARATION 1 OCCUPANCY INSPECTION '
I hereby affirm that I afn licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) r NO. OF EXITS ❑
9 (commencing with Section 7000)of Division 3 of tire Busi-
ness and Professions Code, and my license is in full force and .PARKING
effect. . REQ'D O PROVIDED D
SPACES
License Number Lic.Class
LIMITED TIME USE
Contractor Date I ! DATE DATE
❑ _
I am exempt from the licensing requirements asa FROM: TO:
�I am
licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. OF
SIGNATURE
iness and Professions Code). yq/�j a
PRESENT USE OF BUILDING Vacant medical FINAL APPROVAL
Lic.or Reg.No. Date
office
No.OF EXISTING BUILDINGS
HOME OWNER-BUILDER DECLARATION
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 and Professions Code): NO.PARKING
. SPACES PROVIDED I
❑ I, as owner of the property, will do the work and the # o o 0 o88
structure is not intended or offered for sale (Section
.7044, Business and Professions Code). PROPOSED USE OF BUILDING ., 0 0 0. 0 O 0 0
Med
cal office
CONSTRUCTION LENDING AGENCY .'
0222-52
I hereby affirm that there is a construction lending agency
for the performande 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, TOTAL FEE i
and hereby authorize representatives of this County to enter Pd. to City Of Tem e City
upon the above-mentioned property for inspection purposes. ! P
P SEE REVERSE FOR EXPLANATORY LANGUAGE
:signature of Permittee Date 1
WORKERS'COMPENSATION DECLARATION I' 875(2-80)
CE M I S C E L LA N E O 6 S APPLICATION
CE 875
I hereby affirm that I have 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. BUILDING 1 1 O Q C—.
Lp a�A� 9� �� LOCALITY
❑ ADDRESS A- A- I
Certified copy is.filed with the county building inspectionNEAREST
department. 10 LOCALITY n 1 L C- i C A CROSS ST.
Date Applicant J` NEAREST / �I 1 �,J DISTRICT NO. GROUP PROC SSED BY
K CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' I LEGAL ✓�'7
COMPENSATION.INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. F BLDGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL >_(This section need not be completed if the work involved I TRACT NOWOtl ON LOT USE ZONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars ($100) or less.) USE OF U
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this n cc
permit is issued, I shall not employ any person in any manner WNER/�"`� �� �' �� p( NL O
so as to become subject to the Workers' Compensation Laws. AA AIL OCCUPANCY GROUP
Date Applicant I ADDRESS a UJ
`(� tA1LL S1-{ i� t� 131_V_)
CL
NOTICE TO APPLICANT: If, after making this Certificate of CITY (�° �-( �^� NOI1 I OCCUPANT LOAD 7
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
❑ C] No Spec. Knowl..
deemed revoked. ❑❑
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter I SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS
$ (commencing with Section 7000)of Division 3 of the Busi-
mess and Professions Code, and my license is in full force and PARKING.
effect. I, SPACES ' REQ'D, PROVIDED
.1 cense Number Lic.Class
LIMITED TIME USE
Contractor Date DATE DATE
❑ .
I am exempt from the licensing requirements as.I am a: FROM: TO:
licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). ESENT USE of BUILDING M t j L FINAL APPROVAL
Lic.or Reg.No. Date 1. (J
/3uIA)
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- 5 7 3,9 A
nes,and Professions Code): , NO.PARKING -
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the o a o o 40
structure is not intended or offered for sale (Section
/�
7044, BUSIneSS and PIOfeSS10RS Code). 0 0 0 0 0 0 0 En
- PROPOSED USE OF BUILDING L g J R/1 !0 P
CONSTRUCTION LENDING AGENCY 1 0 $ 1 V-28 2
I hereby affirm that there is a construction lending agency
for the. performance of the work for wjiich 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 I ISSUANCE FEE
above information is correct.I agree to comply with all County
ordinances and State laws relating to building construction, TOTAL FEE
and hereby authorize representatives of this County to enter
MUMU
Toned ropy for inspection urp ses. SEE REVERSE FOR EXPLANATORY_LANGUAGE-11f
Signature of P mittee V D to
WORKERS'COMPENSATION DECLARATION 176M444 ,A C 1 11 //�� AAl1 ci APPLICATION�+ p ry
CE 875 (2-80) MISCELLANEOU!7 APPLICATION
I Hereby affirm that I have certificate of consent to self I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or i I
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company I FOR APPLICANTTO FILL IN BUILDING l�
❑ ESS V ll11
Certified copy is hereby furnished. I BUILDING ^ '•
aADDRESS 00 Lq5 [J/�1 q C' LITY
Certified copy is filed with the county building inspection
department. I LOCALITY C�OSS ST.
Date Applicant NEAREST w I ,, ) DISTRICT NO. G O TYP PROCESSED BY
CROSS ST. �✓ )9/v 4 I CONST. /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
DESCRIPTION LOT No. BLOCK I '
COMPENSATION INSURANCE MAP (CIRCLE)
STATE MAJOR SECOND LOCAL CL
I NO. OF SLOGS. No. (cllxeLE) O.
• (This section need not be completed if the work Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars ($100) or less.) I I U
USE OP �
I certifythat In the SIZE OF LOT EXISTING BLDG. tX
performance of the work for which this _ 0
permit is issued, I shall not employ any person in any manner I OWNER 4��
so as to become subject to the Workers' Compensation Laws. MAIL jUS c/��� /L I OCCUPANCY GROUP ®. U
ADDRESS I
Date Applicant � .• r/7
NOTICE TO'APPLICANT: If, after making this Certificate of CITY �� µ/ms, NoL OCCUPANT LOAD
Exemption, you should beconie subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR i EXIT HARDWARE:
with comply with such provisions Or this permit shall be TRAILER USE GEOLOGY INSPECTION No Spec. KIIOWI.
deemed revoked. i
LICENSED CONTRACTORS DECLARATION I OCCUPANCY INSPECTION Panic DeVICBS ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 1--I (LIST ITEMS BELOW) NO. OF EXITS ❑
9 (commencing with Section 7000)of Division 3 of the Busi- '
ness and Professions Code, and my license is in full force and I i
effeit. I PIf RKING
SPACES REO'D'D PROVIDED
License Number Lic.Class
I I I LIMITED TIME USE
Cdrtractor DateDATE DATE
F +OM TO:
F1I am exempt from the licensing requirements as I am a OF E IZ
licensed architect or a registered professional engineer SNo. OF � �„ �;. INSPECTOR, 'S
acting in my professional capacity (Section 705.1, Bus- EXISTING BLDG. STORIES ♦I'� SIGNATURE.
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL '+
Date
Lic.or Reg.No. y ^
C
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 i
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the I -2 5 3 u,6'A
structure is not intended or offered for sale (Section
7044, Business and Professions Code). PROPOSED USE OF BUILDING 4,0
CONSTRUCTION LENDING AGENCY o 0 0 0 0 0 o z
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 0 a 0 2—8 2
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 r�
ordinancesAnd State laws relating to building construction, TOTAL FEE 25 .00 (Pay to City of I Temple City)
and hEym
horize representatives of this County to enter
upontioned property for inspec ion p poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
/ ^ /S
Si ature of Permittee Date
WORKERS'COMPENSATION DECLARATION . I CE 875 (2-80)76M444 MISCELLANEOUS APPLICATION,
I hereby affirm that i have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'
rs'Compensation Insurance,orl
i
a certified copy thereof(Sec.3800,Lab.C.) '
Policy No. Company FOR APPLICANT TO FILL IN AIS
UILDINDDRESS
❑ Certified copy is hereby furnished. BUILDING q�yoO / S S r
-/ T f-[Q] LOCALITY
ADDRESS 1 /% TO NfF T,
Certified copy is filed with the county building inspection) ���/e NEAREST
department. LOCALITY• d;-t CROSS ST.
Date Applicant NEAREST �/]] �) p, a !DISTRICT NO. GROU TYP PROCE SED I�,Y
CROSS ST. k'j9 PrIn/J V �(�/ R CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 1�v r//
COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
No. U (CIRCLE) STATE MAJOR SECOND LOCAL }
NO. OF BLDGS. Q�
(This section need not be completed if the work Involved TRACT NOW ON LOT USE Z NE SPECIAL CONDITIONS O
by the permit is for one hundred dollars' ($100) or less.)r U
USE OF I �q
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this' _ ft
permit is issued, I shall not employ any person in any manner OWNER AU S 7/X) N ALS e0 I
so as to become subject to the Workers' Compensation Laws. AIL ^^ ^a OCCUPANCY GROUP
rn�s &) L_ U
Date Applicant ADDRESS 029 7- s�I K` )'I//) nW.
TEL.
41
NOTICE TO APPLICANT: If, after making this Certificate of�• CITY L, No. � �A/� ; OCCUPANT LOAD
Cn
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 beI TRAILER USE GEOLOGY INSPECTION
deemed revoked. ❑ C] No Spec. Know).
❑
LICENSED CONTRACTORS DECLARATIONOCCUPANCY INSPECTION I Panic Devices- ❑
I
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 Division 3 of the Busi-,
andness Professions Code, and my license is in full force and
effect PARKING.
SPACES REQ'D E:::= PROVIDED
License Number Lic.Class
LIMITED TIME USE
Contractor Date I DATE DATE
❑ FROM: TO:
I am exempt from the licensing requirements as I am a I
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional Capacity (Section 7051, Bus- EXISTINGBLDG. STORIES SIGNATURE'
iness and Professions Code). 'I P
RESENT FINAL APPROVAL USE OF BUILDING � Q.L V�..-
Lic.or Reg.No. Date «fI
rn&d Nom.
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USF
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 �7
SPACES PROVIDED z 364 6 A
❑ I, as owner of the property, will do the.work and the
structure is not intended or offered for sale (Section '#'o e'o e 8.8
7044,Business and Professions Code).
PROPOSED USE OF BUILDINGI
-/ C IUNJ O O O O O O O Z
CONSTRUCTION LENDING AGENCY m pl,C�I pLy C e 1
I hereby affirm that there is a construction lending agency I 0 4 1 4'—82
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). i
Lender's Name PROPOSED MAX. OCC.
Lender's Address PERMIT FEE 25 .00
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, TOTAL FEE
and hereby,authorize representatives of this County to enter r1n Pair to the City of Temple City . "
y n the above-mentioned property for inspection purposes, SEE REVERSE FOR XPLANATORY LA GUAGE
na ure of Permittee Date
i
WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affirm tl'at I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES ,BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec.3800,Lab.C.) I i
Policy No. Company I BUILDING Cf/]f/�
r
D Certified copy is hereby furnished. uILDING FOR APPLICANT TO FILL IN pDD RESS
A DRESS 7 t /, .0 JOC ALITY
D
Certified copy is filed with the county building inspection NEAREST
LOCALITY .
department. l i GROSS ST.
Date Applicant I EAREST �. j f DISTRICT NO. G OUP TYP PROCESSED BY
CROSS ST. 11v CAVF
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT'NO. BLOCK MAp HIGHWAY }
Ivo. (CIRCLE) STATE MAJOR SECOND LOCAL I-
NO. OF BLDGS.
('Phis 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 ($100) or less.) i
USE OF ,
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this f O
permit is issued, I shall not employ any person in any manner V OWNER (,h 1XeAJ A6t1Li'
so as to become subject to the Workers' Compensation Laws. ! AIL OCCUPANCY GROUP W
I ADDRESS 7
Date Applicant ` +OD')�y 5 �� �0 CL
NOTICE TO APPLICANT: If, after making this Certificate of 'I CITY 71)K !it Cry T. ,2$S" OCCUPANT LOAD _
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth- I
with comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION I NO Spec. Knowl. ❑
dei mad revoked. �
OCCUPANCY INSPECTION Panic Devices ❑
'.' LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) I NO. OF EXITS
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
I S�ACES REO'D D PROVIDED
License Number Lic.Class I LIMITED TIME USE
• f
Contractor Date. I II DATE DATE
❑ PROM: , TO:
I am exempt from the licensing requirements as I am a i
licensed architect or a registered professional engineer SIZE OF NO. OFINSPECTOR'S
acting in my professional Capacity ($eCt10R 7051, $US- EXISTING BLDG. STORIES I SIGNATURE
iness and Professions Code). f FINAL APPROVAL _
PRESENT USE OF BUILDINGed f cA ^
� A/o
Lic.or Reg.No. Date `{ 'Yma ( 7
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): NOPARKING
SPACES PROVIDED
DI, as owner of the property, will do the work and the i # e o-'D D 40
structure is not intended or offered for sale (Section '
7044, Business and Professions Code). I D'o D a D a D Ly
ROPOSED USE OF BUILDING ,
CONSTRUCTION LENDING AGENCY II 0'7,2 0—8 2
I hereby affirm that there is a construction lending agency C-+n y I s
6JJTe-
e
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). i
Lender's Name I PROPOSED MAX. OCC.
Lender's Address I I
I PERMIT FEE 25 .00 ' ,
I certify that I have read this application and state that the
above information is correct.I agree,to comply with all County I ISSUANCE FEE
ordinances and State laws relating to building construction, TOTAL FEE 25 .00 pay to the City- of Temple City
and hereby authorize representatives of this County to enteri
upon th above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY'LANGUAGE !
Signature o ermittee Date
I
i
WORKERS'COMPENSATION DECLARATION 76M444 p A y�p I�®g t APPLICATION ftp 1 A T o A 1
CE 875 (2-80) [� A��I fG V A I� ` A ! ��I
I hereby affirm that I have a certificate of consent nc 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 ADDRESS
❑ Certified copy is hereby furnished. ILDING
S ly LOCALITY
ABUDDRES
E] Cs
Certified copy is filed with the county building inspection9700 Past- Last NEAREST
department. C LOCALITY Temple City, CA 91780 CSOss ST.
Date Applicant NEAREST DISTRICT NO. r GROUP .PRO SSED BY
CROSS ST. Kauffman Ave. �/) ONST��7
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY }
NO. (CIRCLE) STATE MAJOR SECOND LOCAL a
NO. F BLDG..
(This section need not be completed.if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this Q
permit is issued, I shall not employ any person in any manner owlvER - Hall
U
. OCCUPANCY GROUP
so as to become subject to the Workers' Compensation Laws. tgt3tln S
MAIL ^-y W
'DREss':• '975 Wilabire Blvd, Suite 512 0-
Date Applicant — — -
NOTICE TO APPLICANT: If, after making.this Certificate of[,..rIT.Los .Angeles•, CA.. Ivo ��213)�+87-4848 OCCUPANT LOAD z
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
deemed revoked. NO Spec. Knowl. ❑
Panic DeVICBS ❑
LICENSED CONTRACTORS DECLARATION G OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 1 (LIST ITEMS BELOW) i NO. OF EXITS E:19 (commencing with Section 7000).of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect' PA
- SPACES REq'D O I PROVIDED D
License Number Lic.Class
.'� LIMITED TIME USE
CoAractbr 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 I1 SIGNATURE
iness and Professions Code). FINAL APPROVAL /j
JQRESENT USE OF BUILDING , y•'�� V
Lic.or Reg.No. Date_ , . Independent Medical (::.
r-:
=Referee Laborator.i" Medical Bldg.
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 /
) �'U �
❑ I, as owner of the property, will do the work and the SPACES PROVIDED OU
structure is not intended or offered for sale (Section i �� e c c . 8. F
7044,Business and Professions Cdde). PROPOSED USE of BUILDING
` O C O C•
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency Reference LaboratoryI 02 02_84
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, TOTAL FEE
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes. SERREVERSE FOR EXPLANATORY LANGUAGE .
1
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION76M444 CE 875(2-80)
SC E 1L�LANE®V APPLICATION
I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'
rs'Compensation Insurance,or � r
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANTTO FILL IN BUILDING p�
❑ , ADDRESS
Certified copy is hereby furnished. I BUILDING / 7ao �• LAS T��®s ��Jt LOCALITY
ADDRESS 6 • �C 34
Certified copy is filed with the county building inspection �/ NEAREST
department. I LOCALITY /C CROSS ST.
Date Applicant ArEAREST DISTRICT NO. G OUP T @@@ PR ESSED BY
CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL +�' ~ G/•��
'COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIG HwAY
STATE M OR SECOND LOCAL
NO. OF BLDGS. No. (clRel.e) d
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS O
by the permit is for one hundred dollars ($100) or less.) U
USE /)
' SIZE OF LOT EXISTING BLDG. r /
CC
I certify that in the performance of the work for which this `J
permit is issued, I shall not employ any person in any manner ' WNER 4(/!s?//)/,S, �/.4LL F
so as to become subject to the Workers' Compensation Laws. �; AIL /�( T�,f J�yJ OCCUPANCY GROUP rJ
Date Applicant i ADDRESS pJOO �. `4� �•��� vK. � � W
TL
NOTICE TO APPLICANT: If, after making this Certificate of cITY 2�s PL& C/'/ No. ��- ��! OCCUPANT LOAD
Exemption, you should become- subject to the Workers' ; APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be ' TRAILER USEE] GEOLOGY INSPECTION
C] No Spec. Knowl.
deemed revoked. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter I SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and I PARKING.
effect. SPACES REQ'D O PROVIDED D.
License Number Lic.Class i LIMITED TIME USE
i�ontractor Date I DATE DATE
FROM: TO:
❑ I am exempt from the licensing requirements as I am al
licensed architect or a registered professional engineerl; sizE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus-!,' EXISTING BLDG. STORIES i SIGNATURE
iness and Professions Code). lFINAL APPROVAL
I SENT USE OF BUILDING _
Lic.or Reg.No. Date i'
• !I'J�/C.e-L Btci�D/NGS , .
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND-USE
I hereby affirm that, I am exempt from the Contractor's j
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKINGO -2 lJ O 11 f1•
I, as owner of the property, will do the work and the SPACES PROVIDED 1
structure is'not intended or offered for sale (Section I }'$ o 0 0 0 8-8
7044, Business and Professions Code). m
OPOSED USE OF BUILDING 0 a o 0 0 0 0
I '
CONSTRUCTION LENDING AGENCY I C T� C/N� �(iLG�G(irZG Lf�Cr i 011.09-84
a
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.). I � a111W"9- /�,-?-V 1 L11VdZ
Lender's Name PROPOSED MAX. OCC.
I I
i
Lender's Address PERMIT FEE
I certify that I have read this application and state that the I
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to'building construction, I TOTAL FEE �j
and hereby authorize representatives of this County to enter ( v2 Ji
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of P littee Date
i
WORKERS'COMPENSATION DECLARATION 5i CE 87 (2-80) M i S C E L LA NE®V i S APPLICATION®®LICATI0N
I hereby affirm that I have a certificate of consent to self ®LINTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,olr ,
a certified copy thereof(Sec.3800,Lab.C.) 1
Policy No. CompanyFOR APPLICANT TO FILL IN ADDRE1LDING 477
SS (/ [�• /I
❑ I 1
Certified copy is hereby furnished. i wDl REss 9700 •E.Las Tunas Dr.• LOCALITY
❑ Certified copy is filed with the county building inspection I NEAREST
department. OCALITY Temple Cit C a. 1 8o CROSS ST.
• i
Date Applicant I AREST DISTRICT NO. G UP TYPE IPROCrasp*o BY
ROSS ST. /ISS � CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 3.2 I y(�
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY }
No. (CIRCLE) 'STATE MAJOR SECOND OCAL O.
. NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPE CI.AL CONDITIONS V
by the permit is for one hundred dollars ($100) or less:) USE OF
SIZE OF LOT EXISTING BLDG. i W
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 NER Young Shing Chun
so as to become subject to the Workers' Compensation Laws. IL OCCUPANCY GROUP lL
Date Applicant DDR ss 116-2 E. Commonwealth N
NOTICE TO APPLICANT: If, after making this Certificate of Iry TEL.
3_2R3_ 1 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. I
LICENSED CONTRACTORS DECLARATION I OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi- i ❑
ness and Professions Code, and my license is in full force anld b
effect. I PARKING SPACES REQ'D PROVIDED
I
License Number Lic.Class
LIMITED TIME USE
Contractor Date I I DATE DATE
F-1I 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, BR)S- EXISTING BLDG. STORIES S GNATURE
iness and Professions Code). i SENT USE OF BUILDING medical building FINAL APPROVAL
Lic.or Reg.No. Date ` (f
• I
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that- I am exempt from the Contractor's '
2181.OA
License Law for the following reason (Section 7031.5, Busi- , # 0 0 0 0 88
ness and Professions Code): No.PARKING
PSPACRSROVIDED 0 0 0 0 0 0 0
❑ I, as owner of the property, will do the work and thestructure is not intended or offered for sale (Section
i7044,Business and Professions Code). USE OF BUILDINGmedical building
0 4,0 5=8 5
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.
i
Lender's Address PERMIT FEE
I certify that I have read this application and state that the
above information is correct.Fagree to comply with all Couniy ISSUANCE FEE
ordinances and State laws relating to building construction, TOTAL FEE
and hereby authorize representatives of this Coun to enter 1
upo he ab ti ed property for insp� n�rpose�s. SEE REVERSE FOR EXPLANATORY LANGUAGE j
Signature of Permittee Date
F WORKERS'COMPENSATION DECLARATION I 76M444 g��
CE875(2=80) MISCELLANEOUS,, APPLICATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or ' COUNTY®F LOS ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company ` FOR APPLICANT TO FILL IN BUILDING +�/� pill
❑ ADDRESS ( �(�
Certified copy is hereby furnished. ILDING /J
LOCALITY
ADDRESS 9700 Las Tu as 1
❑ Certified copy is filed with the county building inspection ! NEAREST
department. 'LOCALITY Tem le Cit CROSS ST.
Date Applicant I AREST DISTRICT N G OUP JCYPE / PROM D BY
i L CROSS ST. 'J ONST}/
CERTIFICATE OF.EXEMPTION FROM WORKERS' LEGAL (� «<///
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP/E+y►�.s ! q HIGX WA; "
_
N..160-2,4 2,4 L(cIRCLEI STATE MAJOR SEC ND LOCAL O
NO. OF BLDGS.
(This section need not be completed if the work involved '" TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS U
by the permit is for one hundred dollars ($100) or less.) USE of
' SIZE OF LOT EXISTING BLDG.
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 RL''E -Kaiser Foundation Health Plan Inc U
so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP IJJ
ADDRESS 343 E. WAlnut St, c/o Gen. Acct a'
Date Applicant i to
NOTICE.TO APPLICANT: If, after making this Certificate of 4.TY Pasadena NOL. (818) 405-5180 OCCUPANT LOAD z
Exemption, y.ou should•become subject to the Workers' , APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth- i
with comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION No Spec. Knowl.
.deemed revoked. PenIC Devices El
CONTRACTORS DECLARATION OCCUPANCY INSPECTION I
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS-BELOW) I NO. OF EXITS ❑
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and j
effect. PARKING
SPACE'S REq'D P.ROVID ED
License Number Lic.Class
LIMITED TIME USE
Contractdr Date'— DATE - DATE
❑ FROM: TO: _
I am exempt from the licensing requirements as I am'a I INS EcroR's
licensed architect or a registered professional engineer SIZE OF NO. OF I GNATU RE
acting in my professional capacity (Section 7051, Bus- EXISTING'BLDG. STORIES
iness and Professions Code). FINAL APPROVAL
L.WESENT USE OF BUILDING Vacant
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- J?4 6 7 0 A'
ness and Professions Code): NO. PARKING ;
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the I # 0 0 0 0 8 8
structure is not intended or offered for sale (Section
7044, Business and Professions Code). PROPOSED USE OF BUILDING 0 .52 0=8 6
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency MedicAl Services and
for the performance of the work for which this permit is
issued(Sec. 3097,civ.c.). Outpatient Pharmacy
Lender's Name PROPOSED MAX. OCC. 1U
Lender's Address PERMIT FEE $25.00
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
or 'nances and State laws relating to building construction, TOTAL FEE
a
he
authorize representatives�of thi County to enter 25.00
on a above-mentioned property for in paction purposes. ;SEE REVERSE FOR EXPLANATORY LANGUAGE
� I
Signature of Per i ee at
_ � I
a
WORKERS'COMPENSATION DECLARATION ;76M444
E 876(11-84) M I SC E L LA N EO U S�•A P P L I C A T I O N
• SC
• I hereby affirm that 1 have a certificate of consent nc self I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or � � 1
a certified copy thereof(Sec.3800,Lab.Q. "
Policy No. Company FOR APPLICANT TO FILL IN BUDRESSILDING
AD
Certified copy is hereby furnished. BuyLDINe n
V
Certified copy is filed with the county building inspectionw—* :LO A7 TY �/ / NEAREST
de artment. -= i CR 6SS ST.
Date Applicant " NEAREST DISTRICT O. IGRJJ��UP TYPE ESSED BY
CROSS ST. ,® �( CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Szf �d
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY gTATE MAJOR SECOND LOCAL
NO.OF BLDGS.
NO. (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT US6 ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) I USE OF
SIZE OF LOT EXISTING BLDG. 7••'
I certify that in the performance of the work for which this 1 ! °c:
permit is issued,I shall not employ any person in any mannelkX owNER of building /o :�
so as to become subject to the Workers' Compensation Laws. ' MAIL OCCUPANCY GROUPEa]
ADDRESS r'
Date Applicant I C..I
NOTICE TO APPLICANT: If,after making this Certificate of I CITY(' - G- NO. — i OCCUPANT LOAD
Exemption, you should become subject to the Workers' —
Compensation provisions of the Labor Code,you must forth- I APP ICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be I' TRAILER USE GEOLOGY INSPECTION No Spec. Knowl.
deemed revoked. 11
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 an
effect. PARKING
SP,4CES REq'D D PROVIDED
License Number Lic. Class I120-- TAIVLAI
j LIMITED TIME USE
Contractor Date I DATE DATE
I am exempt from the licensing requirements as I am a PRQMC
licensed architect or a registered professional engineer I SIZE OF No.of I TOC (NSP :TOR'S
acting in my professional capacity (Section 7051, Bus-
iness
us EXISTING BLDG. STORIES S uR
inessandProfessionsCode). /+
PRESENT USE OR BUILDING FINAL APPROVAL �J✓�6�"/
Lic.or Reg.No. Date 1
HOME OWNER-BUILDER DECLARATION I NO.OF EXISTING BUILDINGS
ON LOT AND USE ,
I hereby affirm that I am exempt from the Contractor's �f/
License Law for the following reason (Section 7031.5, Busi-I �V
ness and Professions Code): .1 NO.PARKING
1, as owner of the property, will do the work and the SPACES PROVIDED
ON
structure is not intended or offered for sale (Section)
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY ' PROPOSED USE OF BUILDING
1 Hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is G Y I = •
issued(Sec.3097,Civ.Q. I `�
Lender's Name
PROPOSED MAX.OCC. ' ,y-i
Lender's Address �{ 1
PERMIT FEE
t ? 'j
I certify that I have read this application and state that the9-5.00
I _
above information is correct.I agree to comply with all County,, ISSUANCE FEE
ordinances and State laws relating to building construction:
and hereby author iz presen tives of this County to enter TOTAL FEE 25 QQ _s
upon above-me ion d pro err y r;inspection purposes. ' :--
I — _ - - :=''R; SEE REVERSE FOR EXPLANATORY LANGUAGE
Sianal UTC'of Perm' t c Date ,
1
WORKERS'COMPLINSA I IUN UL•LLAKAIIUN t"/1iN144'4
CE 875(11.84) MISCELLANEOUS APPLICATION •
hereby affirm that I have a certificate of consent to sell' ('OUNTI' Of 1.05 ANGELES IiUll_ )1NG ANI) SAFETY I)1�'1SION
(sure, or a certificate of Workers'Compensation Insurance,or
certified copy thereof(Sec.3800.Lab.C.). r ;,
olicy No. Company FOR APPLICANT TO FILL IN BUILDIN�
ADORES
Certified copy is hereby furnished. BUILDING O .j��de �� L S�tCE
ADDRESS rIJ '�• LO CA LITI',
] Certified copy is filed with the county-building inspection LOCALITY / t NEAREST
department. �; (_ CROSS S7.
)ate Applicant NEAREST DISTRICT NO. GROUP TYPE ����� P ESSED BY
I CROSS ST. CONST.j/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �/
COMPENSATION INSURANCE i DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE)
STATE MAJOR SECOND LOCAL
5
NO.,OF BLDGS.
This section need not be completed if the work involved TRACT NOW ON LOT USE ZON� SPECIAL CONDITIONS
,y the permit is for one hundred dollars (5100) or less.) USE OF
certify that in the performance of the work for which this II SIZE OF LOT EXISTING BLDG. r`
-ermit'is issued, 1 shall not employ any person in any manner OWNER1W
o as to become subject to the orkers' Compensation Laws. I MAIL OC UPANCY GROUP ==,
C~]
late _ y ADDRESS Applicant /� )
40TICE TO APPLICANT: If, after making this Certificate of + CITY Ta..' 313 OCCUPANT LOAD
,:xemption, you should become subject to the Workers'�t APPLICA ON FOR EXIT,HARDWARE:
'ompensation provisions of the Labor Code,you must forth-
Ath comply with such provisions or this permit shall be i TRA ER USC ❑ GEOLOGY INSPECTION EJ � No Spec. Knowl.
seemed revoked.
OCCUPANCY INSPECTION ® Panic Devices ❑
LICENSED CONTRACTORS DECLARATION I
hereby affirm that I am licensed under provisions of Chapter
SAFETY PERMIT ❑' (LIST ITEMS BELOW NO. OF EXITS
I (commencing with Section 7000) of Division 3 of rite Busi- I '
less and Professions Code.and my license is in frill force and c
ffect. SSo Gt a-E-e J
PARKIN SPACESII RECD PROVIDED
.icense Number Lic. Class AdoO S - Wk S4-e A)
LIMITED TIME USE
:ontractor Date Ole Q C.0 C q0 d I' DATE DATE
FROM. TO. INSPECTOR'S
I am exempt from rite licensing requirements as 1 ant a
licensed architect or a registered professional engineer SIZE OF NO. OF SIG ATURE
acting in my professional capacity (Section 7051. BUS- EXISTING BLDG. STORIES
inessand Professions Codel. I FINALIAPPROVAL
I
.ic.or Reg.No. Date I PRESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION I NO. OF EXISTING BUILDINGS 6DU G�
ON LOT AND USE
hereb%. affirm that I ant exempt front the Contractor's
.icense Law for the follow in_a reason I Section 7031.5. Busi-
less and Professions Code): NO. PARKING
] 1, as owner of the property.. will do the workworkand the is
PACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I; I.
hereby affirm that there is a construction lending agency w n_� ll L o FI cJ
or the performance of the work for which this permit is
ssued(Sec.3097,Cir.C.).
..ender's Name i
PROPOSED MAX. OCC.
.ender's Address ( O
certify that I have read this application and state that the 4 PERMIT FEE r�pt
Ibove information is correct.I agree to comply with all County ISSUANCE FEE
)idinan es and State s .relating to building construction, p�q
Ind:ne by utltor' ep esentatives of this Count}• to enter TOTAL FEE
I.
t ab a-mc i e pro e r inspection pur ores. -r1 CJI
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date °" `