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WORKERS'COMPENSATION DECLARATION 76nM444-
CE875 (11-84) MISCIELLANEOUSAPPLICATION {�
I hexeby affirm that I have a certificate''o£ consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION L1
insure, or a certificate of Workers'Compensation Insurance,or ;
a certified copy thereof(Sec. 3800,Lab.C.). ;,•„ J- •
Policy No. Company FOR APPLICANT TO•FILL`IN �'� , BUILDING
ADDRESSZzHza
Certified copy is hereby furnished. BUILDINGn
ADDRESS `\ 2•D L:/ L
LOCALITY �/
t
Certified copy is filed with the county building inspectionLocAi�I'ry' " 't ` NEAREST
TF
department. r L C �n 7 CROSS ST.
Date Applicant NEAREST �S K , \ y') DISTPCT G O EPE
NST. PRISSENBY
C ROSS�ST/. ,P��
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL -
COMPENSATION INSURANCE DESCRIPTION T'NO. 91 BLOCK MAP HIGHWAY
rv0 (CIRCLE) STATE MAJOR CON LOCAL
I NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT 3 USE ZONESPEC IAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) + USE of
SIZE�OF?LOT,� '/l", b 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 OWNER ZZ IW AE ='
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
.ADDRESS
Date Applicant ' L D v r U-1�
TEL: I OCCUPANT LOAD n-
NOTICE TO APPLICANT: If, after making this Certificate of CITY " ,C. NO. _ s
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.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 21 Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter
�/ �SpFETY 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 n
effect. UJ�9 PARKING REQ E1 = I PROVIDED
S S � 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 1 SGN TO R'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IGNATU
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING '
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 ACCTaT
License Law for the following reason (Section 7031.5, Busi- '''I(07 i 9.13Ci
ness and Professions Code): NO. PARKING Fes' " r
SPACES PROVIDED l�'!j -7
I, as owner of the property, will do the work and the 1 _ 3307 � t � t� a�0
structure is not intended or offered for sale (Section r
7044,Business and Professions Code). ITEENa
I
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING TOTAL 93 - 00
I hereby affirm that there is a construction lending agency h` CHECK,' 03.00
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). { CHANGE .00
Lender's Name
PROPOSED MAX. OCC.
Lender's Address OLI `}� i
PERMIT FEE � I 171��1—���� 7/20/5-13
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 13,0 b 1911 7:215
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above mentioned p p rty for inspection pur oses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re of Permittee I ate
COUNTY OF LOS ANGELES TEMPLE CITY _ # 0508 •• MISCELLANEOUS PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS MP 0508 0506230010
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: NO. OF CONST NEW BUILDING ADDRESS:
TR: 11218 LT: 8 BL: E SQ. FT STORIES TYPE OCCUP GROUP 5327 LOMA AV
STRUCTURE. 1 VN C TEMP CA 917803002
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
5388-007-008 EXIST BLDG USE: THOMAS PAGE: 596 GRID: H4 LOCALITY: TEMPLE CITY, C
EXIST OCC GRP: USE ZONE:
TENANT: ISSUED ON: PROCESSED BY: EXPIRES ON:
BLDGS. NOW ON LOT: VALUATION: 06/23/05 JK 12/20/05
0
OWNER: TEL. NO: FT_UL DATE FINAL BY: CODE:
LEWEN, QI (626) 287-8649- LIST ITEMS.
5327 LOMA AVy
TEMP 917803002 DESCRIPTION OF WORK
GARAGE REMOVED WINDOWS, ENCLOSED WITH SOLID WALL, KITCHEN
_ OCCUP LOAD EXIST: SINK & FACILITIES AND BATHROOM REAR OF THE GARAGE STRUCTURE
APPLICANT: TEL. NO: OCCUP LOAD NEW: REMOVED AND CAPPED OFF, MAKESHIFT BETWEEN GUESHOUSE AND
SAME AS OWNER
PARKING SPACES REQUIRED: SPECIAL CONDITIONS:
PARKING SPACES PROVIDED:
EXIT HARDWARE:
CONTRACTOR: TEL. NO: LIMITED TIME USE
SAME AS OWNER - NBR OF EXITS: FROM TO
LIC. NO
FEES PAID
APPROVALS DATE INSPECTOR SIGNATURE
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:
ARCHITECT OR ENGINEER: TEL. NO: _ TRAILER USE
- OA PERMIT ISSUANCE 27.75
LIC. NO: 01 R/M OCC/USE INSPECT 145.95 SAFETY PERMIT
TOTAL FEES 173.70
TEMP. STRUCT. APPROVED
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: TEMP. STRUCT. REMOVED
NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
NO
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS _
NO NO NO
)
REQUIRED TOTAL SETBACK FROM EXIST '
SET BACK YARD: HWY: PROP LINE: WIDTH: _
FRONT PL-
SIDE PL-
* ADDITIONAL DATA ON FILE
REPORT ID: DPR267 ROUTE TO: BS0508