HomeMy Public PortalAbout9607, 9607 1/2 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (2-80) MISCELLANEOUS APPLICATION
I hereby arf.%rm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure. or-5 certificate of Workers'Compensation Insurance,or
a cer{,fied copy thereof(Sec. 3800, Lab.C.)
Policy No. Company FOR APPLICANT TO FILL INBUILDING C� `
ADDRESS
❑ Certified copy is hereby furnished. BUILDINGI LOCALITY
ADDRESS //0�7 /Z Lf�S NQS J
❑ Certified copy is filed with the county building inspection NEAREST
department. 41 LOCALITY L �L-T^j CROSS ST. _
f
Date Applicant AREST /J C DISTRIC O. UP TYPE SSE Y
CROSS ST. CZ �L09- �.y - ^� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V
COMPENSATION INSURANCE
DESCRIPTION LOT NO. BLOCK NO.
OOP (CIRCLE)
HIGHWAY STATE MAJOR SECOND LOCAL
NO. OF BLDGS. (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS .0
by the permit is.for one hundred dollars ($100) or less.) 0
USE OF -
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 manner OWNER
InIz /9/2 win,
so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP V
y'6/ L� Z(/✓/�s - 1J
ADDRESS
Date Applicant a.
TEL.
NOTICE TO APPLICANT: If, after making this Certificate of -T- 7TY,7PI-cL Z-j`"9 No. -7 OCCUPANT LOAD
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
❑ ❑ No Spec. KnowEl
deemed revoked. Panic Devices
El
CONTRACTORS DECLARATION occuvANcv INSPECTION
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-
ness and Professions Code, and my license is in full force and PARKING.
effect. SPACES REO'D D PROVIDED D
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 SIGNATURE
iness and Professions Code'). RESENT USE OF BUILDING FINAL APPROVAL 09_
Lic,or Reg.No. Date ~
arc c. coaos #`o o o,o 88
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE 0 0 0 0 0 0 0
I hereby affirm that, I am exempt from the Contractor's 0'4.'26-'8'3
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
structure is not intended or offered for sale (Section '
7044, Business and Professions Code). oPosEo USE of BUILDING
CONSTRUCTION LENDINGAGENCY
I hereby affirm that there is a construction lending agency fJ_)) 13L� S
for the performance of the work for ,which this permit is
issued(Sec. 3097,Civ.C.). ea-W&Ao 400a
IS
Lender's Name - PROPOSED MAX. OCC. r
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 ��i too
upon thea Ove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORYaeANGUA,
!/ �, �-.- '✓Tim' �---�' �/ �� - .
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (2-80) 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 FOR APPLICANT TO FILL IN BUILDING
ADDRESS y
❑ Certified copy is hereby furnished. UO<UILDING /� ]) //fi�ec -� �y 1 LOCALITY f
❑ - ADDRESS (00 J-,q6 J v,.) AS bP- • .
Certified copy is filed with the county building inspection
NEAREST
department. OCALITY 7Pn7 /e ms's e CC,,• CROSS ST.
Date Applicant AREST /� I t�" DISTRICT NO, G UP TYP PRO ED BV
CROSS ST._
T. e� /C e letv 0�i CON T. +/
CERTIFICATE OF EXEMPTION FROM WORKERS'- LEGAL I a V
DESCRIPTION LOT NO. BLOCK MAP /�/IHIGHWAY
COMPENSATION INSURANCE STATE MAJOR SECOND CAL CL
NO. W® (C.IRCLE) O
- NO. OF SLOGS. _
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONEFCIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.) USE OF
' SIZE OF LOT EXISTING BLDG.
In
I certify that in the performance of the work for which this 0
permit is issued, I shall not employ any person in any manner wNER . �t Ve U
,so as to become subject to the Workers' Compensation Laws. IL Q/ OCCUPANCY GROUP LU
ADDRESS
Date Applicant ` z
Z
NOTICE TO APPLICANT: If, after making this Certificate of �PitlQ t<Y (" NO. OCCUPANT LOAD
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 NO Spec. Knowl. El
revoked. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION pBnIC DBVICeS
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) E:1NO. 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 REO'O D PROVIDED
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
iness and Professions Code). SENT USE OF BUILDINGU 0 c��v*A
�1 FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. of AND USG BUILDINGS J/
ON LOT AND USE
_208a2A
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- • s e e 8
Hess and Professions Code): NO. PARKING SPACES PROVIDED
❑ I, as owner of the property, will do the work and the o • e • o • • z
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 4 0 1 5!`-8 4
SED USE OF BUILDING
CONSTRUCTION LENDING AGENCY i �^
I hereby affirm that there is a construction lending agency C l®T h i /1
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name PROPOSED INA:X.,OCC.
Lender's Address PERMIT FEE _
I certify that 1 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 authori representatives of this County_ to enter TOTAL FEE
upon the Bove-menti ned pr e y for inspect' `purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu Date
WORKERS'COMPENSATION DECLARATION
CE 875(11-84) MISCELLANEOUS APPLICATION
CE 875
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 FI LL IN BUILDING a n
ADDRESS j/
Certified copy is hereby furnished. BUILD INGr LOCALITY
D DR ESS .960712 LAS TUNAS DR.
DCertified copy is filed with the county building inspection LOCALITY NEAREST
department. TEMPLE CITY, CA .91780 CROSS ST.
Date Applicant OAEAREST DISTRICT O TYPE PROC SED BY
CROSS ST. TEMPLE CITY BLVD `� oNSr.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �/
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECONA LOCAL
NO. OF BLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE„LONg SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF //v/.I I
S E 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 manner OWNER
so as to become subject to the Workers' Compensation Laws. ALBERT WM. DRIVER OCCUPANCY GROUP rY
MAIL
IJ F5
O
Date Applicant ADDRESS _9611 LAS TUNAS DR.
LO
NOTICE TO APPLICANT: If, after making this Certificate of clrTEL. OCCUPANT LOAD
Y TEMPLE CITY NO. 28671147 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 El
revoked. TRAILER USE ❑ GEO OGY INSPECTION ❑ No Spec. Know].
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
Panic Devices El
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 �1
effect. PARKING
SPACES REQ'D D PROVIDED
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a
FROM: ro.
licensed architect or a registered professional engineer S 17,k OF NO. OF IN SPE To R'S
acting in my professional capacity (Section 7051, Bus- E ISTING BLDG. STORIES <, SIG ATURE
iness and Professions Code). FINAL APPROVAL v f
Lic.or Reg.No. Date PRESENT USE OF BUILDING RETAIL OF JEWELRY
GIFTS & OFFICE 9 $$'A
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS i
I hereby affirm that I am exempt from the Contractor's ON LOT AND USE D D D 0 8 8
License Law for the following reason (Section 7031.5, Busi- 'o D 6 0 a D D z
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED 0 317,-88
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING RETAIL
I hereby affirm that there is a construction lending agency JEWELRY, GIFTS & OFFICE.
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 hereby authorize representatives of this County to enter TOTAL FEE
u"on the above tinned property or inspection ptyposes. O
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignattfre of Permittee Date � �\
WORKERS'COMPENSATION DECLARATION cE 8454(11-84) M I SC E L LA N EO U S APPLICATION
hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.).
'-Rolicy No. Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS l
Certified co is hereby furnished. BUILDING
copy y ADDRESS LOCALITY
❑ Certified copy is filed with the county building inspection LOCALITY /
NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NOJ GROUP TYPE PROCESSED BY
CROSS ST. CONST.;'
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOF2 SECOND LOCAL
NO. OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for 9ne hundred dollars ($100) or less.) usE of
I certify that in the performance of the work for which this slzE of Lor EXISTING BLDG.
w
permit is issued, I shall not employ any person in any manner OWNER ^--I
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP u
ADDRESS
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY NOL OCCUPANT LOAD CD
a
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth PPLICA-KON FOR EXIT HARDWARE: w
with comply with Such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION
❑ No Spec. Knowl.
p ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION E] 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 _ LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF NCTOR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGGNATURE
iness and Professions Code).
FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date IS,]
r
444_4 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 Int+
I, 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).
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
MIT FEE
I certify that I have read this applitation 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 representatives of this County to enter TOTAL FEE
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee' Date -
WORKERS'COMPENSATION DECLARATION 76M444
CE.875 (2-80).: MISCELLANEOUS APPLICt4TION
1 hereby affirm that I have a certificate o f.ionconsentlnsur 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. BUILDING
Company FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished. BUDDING C LOCALITY,
ADDRESS ~� (/�. -+ -L (r
❑ Certified copy is filed with the county building inspection / NEAREST
department. Lo ALITY /� G( CROSS ST.
Date Applicant NEAREST / DISTRICT NO.. GROUP TYPE C ED BY
CROSS ST. _ -.!`�. CONST.
CERTIFICATE OF EXEMPTION.FROM-WOR KERS. LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY; }
NO. �j�Q (GIRC LE) SAAO
STATE MAJOR SECOND LCAL >
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE, ITION
SP CIAL CONDs 0
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 0
permit is issued, I shall not employ any person in any manner .wNER rl a I—
so.as to'become subject to the Workers' Compensation Laws. IL v OCCUPANCY GROUP W
ADDRESS �I✓`Q"_S a
Date Applicant � y
NOTICE TO APPLICANT: If, after making this Certificate of ITr" f ` ` N0. U� l� 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. C3 No Spec. Knowl. ❑•
LICENSED CONTRACTORS DECLARATION OCCUPANCY uvsPEcrloN
Panic Devices El
I hejeby affirm that I am licensed under provision's of ChapterSAFETY PER ❑ (L157 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 PARKING.
e'iY cast. - SPACES R EO'D O PROVIDED D
License.Number Lic.Class
LIMITED TIME USE
Contractor Date 'GATE 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 SIGNATURE
iness and Professions Code). FINAL APPROVAL _
ESENT USE OF BUILDING.
Lic.or Reg.No. Date Z11A�IA✓,
HOME OWNER-BUILDER DECLARATION ON LOT AND USE No. of EXISTINGUSE BUILDINGS
I hereby affirm that, I am exempt from the Contractor's �.2•Q �•9 A
License Law for the following reason (Section 7031.5, Busi- ,
ness and Professions Code NO.,PARKING {�
). 'SPACES PROVIDED - }} D G - 88 8
❑ I, as owner of the property, will do the work and the }'
structure is :not intended or offered for sale (Section, o o'o 0,0 o.o.EO
z
7044; Business and Professions Code).. .POSED USE OF BUILDING
04:18-84
' CONSTRUCTION LENDING AGENCY
I hereby affirm that 'there is a construction lending agency Q ��
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 hereb uthorize representatives of this County to enter
upon th �^ ve-mentioned perty for inspectiylJurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of PgWnittee � ?, Date
76
WORKERS'COMPENSATION DECLARATION, CE g,5(11-84) MISCELLANEOUS APPLICATION
I Hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or fl
r! a certified copy thereof(Sec. 3800,Lab.C.).
_ ING
Policy No. Company FOR APPLICANT TO FILL IN ADDR ESS5
'ADDRS
Certified copy is hereby furnished. g BUILDING / �� dui/� S —� LOCALITY / /7
ADDRESS
i Certified copy is filed with the county building inspection g LOCALITY NEAREST
department. T�, «. cRoss sr. (/�f
Date Applicant NEAREST �� / / DISTRICT NO. G OUP TYPE P CESSED BY
CROSS ST. /��^C,� t'� CONSSA9 p
i CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (J v
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
No. (CIRCLE)
STATE MAJOR SECOND LOCAL
NOOF BLDGS.
(This section need not be completed if the work involved TRACT NO.W ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (SI00) 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 X OWNER Z/U jz
so as to become subject to the Workers' Compensation Laws. X MAIL / -,d OCCUPANCY GROUPEa::]
! Date applicant ADDRESS �(p0 —7.
— g r. .rE !< -
NOTICE TO APPLICANT: If, after making this certificate of CITYe_ _ No. OCCUPANT LOAD
5 !�3 .
Exemption, you should become subject to the Workers' gppLlC ION FO =�: I-' 7,')j 4 EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth -
1 with comply with such provisions or this permit shall be TRAILER USE fJI GEOLOGY INSPECTION 1__� No Spec. Knowl.
deemed revoked.
- LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION [X 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 REO•D D PROVIDED
N
License Number Lic. Class —
LIMITED TIME USE
Contractor Date
DATE DATE
n I am exempt from the licensing equirements as I :nn a INSPECTORS
n 1 licensed architect or a registered professional engineer SIZE OF i N0. OF SIGNATURE
? acting in my professional capacity: (.Section 70a 1. BLIS- EXISTING 3LDG. STORIES
_ iness and Professions Code).
PRESENT USE OF 3UILDING FINAL APPROVAL
v Lie.or Reg. No. Date
I
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS I _
ON LOT AND USE
[ hereby affirm that i sm exempt from the Contractor's
I License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
EJ1, as owner of die property. will do the %vork ane the SPACES PROVIDED
structure is not intended or offered for .sale iSection
7044.Business and Professions Code). p
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING .AGENCYA
I liereby affirm that there is a construction lending ag- ncy /for the"the performance of the work for which this pern':it is
issued(Sec. 3097,Civ.C.). I
Lender's Name
PROPOSED MAX. OCC. CD
Lender's Address 00.
25 °teary{
( - PERMIT FEE
I certify that I have read this application and state tha'c the ri-I
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to :anter TOTAL FEE 25.00
I upon the above-mentionedtproperty for inspection purpos;�S. F `
_ I SEE REVERSE FOR EXPLANATORY LANGUAGE �•�
451^natlDLU ii;e Dail
I WoR1:ERs coNIPENsAT►oN DECLARATION t� 841
87 4
CE 875 MISCELLANEOUS APPLICATION
CE 8 �
I hereby affirm that I have a certificate of consent to self I
insure. or a certificate uCiVorkers'Cutnaensation insurance.or COUNTY OF LOS .ANGELES BUILDING .AND SAFETY DIVISION
(— a certified copy thereof(Sec. 3800.Lab.C.I. -
Policy No. _Compan}' FOR APPLICANT TO FILL IN BUIDRLDEING �e
ADSS
Certified copy is hereby furnished. BUILDING
AD DRE55 LOCALITY
I Certified copy is filed with the count building inspe'c'tion LOCALITYNEAREST
department. Temple City CROSS ST. �v
Date Avolicant NEAREST // DISTR IC NO. GRO P TYPE CESSED BY
CROSS ST. / I✓t u(�t(.Q� CONS
I CERTIFICATE OF EXEMPTION FROM 'iORKERS' LEGAL
COMPENSATION INS( R.1N(L OESCPIPTION LOT NO. 'BLOCK I MAP GRw Av
Flo I
NO. OF SLOGS. STATE MAJOR SECOND LOCAL
I (CIRCLE
(This section need not be completed If the %fork involved RACT NOW ON LOT JSE ?ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars 6100) or less.) i —+
USE OF
( T 1
I certif}• that in the ncrformance of t!:z �.�.xl_ 'or which tSIZE OF LOEXISTING BLDG.
his - _
Permit is issued. 1 shall not employ any azrson '.n any manner OWNER
so as to become subject ;o the �korkers' Compensation ms. MAILOCCUPAC`' 3ROUP _
I Date kpplicant AD OR ESS N
Gl{o�l L�tS T o, 5 D6I)e—
_E
NOTICE TO APPLICANT:INT: If, alto: makinc !tis Cert icare oi gj CIT-- Ie M 4 �n No. 6a)2-Q'(,- it 4-7 OCCUPANAC
L
Exemvtio-l. you <llould become subject :o the Worke: '
l'ompens tion ero:isions of the Labor -.dz. you must Huth_ APDL!CA71C^•! FBF _X I- HA 0IAI A�_with comni%- %Pith we'll nroyts:Iln.s 07 .his :-.e'rnlit sllail be -RAILER JSE !� GEOLOGY :NSPECT.!CN ! nr i
deemed :e)okedNo So
. — ec. < otwl.
- LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$$ f an;c Devices
I hereby affirm :hat 1 am licensed under previsions of Chanter
9 Icommencine Willi Section 0001 of Division 3 :)I the Bltct- SAFETY PERMIT u (LIST ITEMS 3ELOtY) NO. OF EXITS
ness and P:nfessions Code. and my license is in :till gorse and
effect. PARKING REO O i PROVIDED
SPACES
License Number Lic. Cass LIMITED TIME USE
Cuntral.tor— — Date_ DATE DA-r
N lam exempt from the licensing reauvementc as I am 1 TO:
m I licensed architect or a. registered professional engineer Size of No, OF INSP CTOR•S
Z act m2 in my professional -0;l.
::lracit•: ��:;io:l f3ut - EXISTING BLDG, ST OP.IES S1 ATURE
v (ness lilt P-ofessicris l-
:)del. ---
Ij PRESENT USE OF BUILDING FINAL.APPROVAL
., Lic.or Ree- No.
HOME Ot�N► R-BUILDER DECLAR.\r10\ NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I :un exempt from the Contrartor"s
i License Law for the following reason ISection'-931.;. Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED
D I, as owner of the property. will do :he )vork and the
structure is not intended or offered for iale (Section
( 104.1.Husiness and Professions Code).
CONSTRUCTION LENDING .AGENCY X PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency a L^e, C,(L4, n,
1 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 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 relatinL to buildim construction.
t and hereby authorize epresentatives of this County to enter TOTAL FEE 25.00
I I upon the above-ment' tie property for inspection Purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Siena re o erinittee Date
)
WORKERS*COMPENSATION DECLARATION CE 87 H1-84) MISCELLANEOIjSAPPLICATION
I
. I hereby affirm that I have a certificate of consent tc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
�1�I a certified copy thereof(Sec.3800,Lab.Q. _
c=J
LDING
AS Policy No. Company FOR APPLICANT TO FILL IN BUIESS
Certified copy is hereby furnished. g nooness LOCALITY
! Certified copy is filed with the county building inspection % NEAREST LOCALITY
department. �,C{ CROSS ST. /
Date Applicant NEAREST -�• / C DISTRICT N?. G OUP TYPE ,/ P CESSED BY
CROSS ST. / is /`�--� RI CT y i CONSS/7
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (i DISTRICT"
ddd
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
HG. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF SLOGS.
(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 (S100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which -his —
permit is issued, I shall not employ any person in any manner V OWNER
so as to become subject to the Workers' Compensation Laws. % MAIL OCCUPANCY GROUP
ADDRESS
Date .applicant % _
rEL. 'J2 OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY No. �7 J �,�
Exemption, you should become subject to the Workers' -
Compensation provisions of the Labor Code. you must torth- APPLIC ION FO _ EXIT HARDWARE:
1 with comply with Such provisions oI this permit ,hall be TRAILER USE n GEOLOGY INSPECTION 1= No Spec. Knowl. G
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION B
O 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 REO'D PROVIDED
rn SPACES
License Number Lic. Class —
LIMITED TIME USE
w
Contractor Date DATE DATE
w
❑ I am exempt IIom -lie licensing requirements as I im i
a I licensed architect or a re_isteied professional an_ineer 311E OF NO. OF INSPECTOR'S
2 acting in my professional capacity iSection -05 1. Bus EXISTING 3LDG. I STORIES SIGNATURE
o
iness and Professions Code). FINAL APPROVAL _q8
PRESENT USE OF 3UILDING
U Lic.or ReE. No. Date
I
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. Susi-
ness and Professions Code): NO. PARKING
1, as owner of the property, will do the work anc. the SPACES PROVIDED
structure is not intended or offered for ;ale (Section
1044.Business and Professions Code).
CONSTRICTION LENDING AGENCY % PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency p
I ) for the performance of the work for which this pem it is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address 25.00
I I certify that I have read this application and state than the PERMIT FEE
above information is correct. I agree to comply%%ith all County ISSUANCE FEE m
ordinances and State laws relating to building construction,
and Hereby authorize representatives of this County to :anter TOTAL FEE 25.00
l upon the above-me9tioned)pro perty for inspection purpos_s. 1 `
SEE REVERSE FOR EXPLANATORY LANGUAGE C�
MCISi�natt.A of_�tmittee Date
WORKERS*COMPENSATION DECLARATION a
CE 875 1 l 841
MISCELLANEOUS APPLICATION
CE 87 �
I herebv affirm that I have a certificate of consent to self I .
insure, or a certificate ot'Workers'Compensation Insurance.or COUNTY OF LOS .ANGELES BUILDING .AND SAFETY DIVISION
a certified copy thereof tSec. 3800,Lab.C.I.
Policy No. --company — Fpq APPLICANT TO F!LL IN Bu1LDING�/
❑ ADDRESS
Certified copy is hereby furnished. eu ILo1NG ��7��
ADDRESS U Z S ,(N YAS Q(t Ue, LOCALITY
I
Certified lope is tiled with [Ite county building inspection LOCALITY NEAREST
department. Temple City CROSS ST.
Date Applicant NEARESTDISTRIC NO. GRO P TYPE CESSED BY
CROSS ST. J _ uVsl�j� CONS
I
CERTIFICATE OF EXEMPTION FROM '1GRKERS- LEGAL GtGs
CONIPENSATION' INS( RAN(1•= DESCPIPT:ON LOT NO. BLOCK I MqI+ FIIG ww AV
ND, ) STATE MAJOR SECOND LOCAL
I NO. OF SLOGS. (CIRCLE)
(This section need not be completed If the work Involved -RAC- NOW ON LOT USE !ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars +5100) or less.) USE OF
I SIZE OF LOT EXISTING BLDG.
I certify that in the performance of -!:e work- 'or which -his
permit is issued. I shall not employ any person in am'manner OWNER71
so as to become subiect :o the Aorkers' Compensation !,axis. XI —
MAIL A 11 r'�� OCCUPANC" .;ROUP
ADDRESS
Date Applicant —\ \\ / As TvAcAS D,,I1e-- -
-E,-.
NOTICE T J APPLICANT: If. af-er making -!: ^
is t:e :.irate nr $]CIT-- efh (,�1,. Nc. &0Z('(,- 114-7 OCCUP4N- LOAD,
Exemotio-i. you should become subJect -o -fie %,rkers'
lompensation erocisions Iii the I_;tbcr -,ode. you must tort h. APO LICA 71 C111 C-1F _X 17 yACC` iiA _ -
1 with compiv ,cith <uch nrovis;ons o- his •-erniit shad be GEOLOGY :NSPEcr.eN — f^
No Soec. Knosvl.
deemed:e oked. -RAILER USE GEOLOGY
— <✓
LICENSED CONTRACTORS DECL.-kRATION OCCUPANCY INSPECTIONS Panic Devices
I hereby affirm :hat I am licensed under OLCvlSlln$of Chanter SAFETY PERMIT u a
1 (LIST ITEMS SELO'W)
9 tmmmencing with Section 70001 of Division 3 .)f the Buri- No, of EXITS
ness and P-nfessions Code, and my licence is in :uII for,,- and j
effect. 1 4 x PARKING REO O I I PROVIDED
SPq CES ��
License Numher Lic. C!as. _ 4 C
LIMITED TIME USE
N
Contractor___ I�sll'___--_.__--_ 7ATE DATE
W
W
H I am exempt from the licensing reauirements as I am .I TO:
D
1 licensed architect or a. re_istered professional -n2ineer 31ZE OFNO, OF INSP CTOR'S
z actin^- in -nv professional ::1["l:a i': S2:lion -o`�I. Rtl C- EXISTING BLDG.
3.ORDS ATURE
a lness jnd hrotesslcns
L./ FINAL APPROVAL
Lic.or Re_. No. ('RESENT USE OF BUILDING_ D:i:e lZ' -- --
11011E 011 N!-R-BUILDER DECL.a RATION NO. OF EXISTING BUILDINGS n
ON LOT AND USE
1 hereby affirm that I am exempt from the Contractor's
License Lain for the following reason (Section -031.5. Bu<i-
ness and Professions Code): NO. PARKING
SPACES PROVIDED
I, as ,owner of the propertn, will do :L•e work and the
structure is not intended or offered for rale (Section
704.1-Business and Professions Code).
CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING
I herebv affirin that there is a construction lending aaenev
I for the performance of the m ork for which this p'ermit is
issued ISec. 3097,Civ.C.).
Lender's N:une
PROPOSED MAX. OCC.
Lender's.address —
I I certify that I have read this application anti state that the PERMIT FEE 25,00
above information is correct. I:free to comply with all County ISSUANCE FEE
• ordinances and State laws relating to building construction,
• and herebv autWittee
esen atives of this County to enter TOTAL FEE 25�(KI
1 upon the above- property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGU 1GE•
Siena Date
I -
i _ I