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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