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Home My Public Portal About9574-9576 LOWER AZUSA RD_Miscellaneous__ WORKERS COMPENSATION DECLARATION cE 76M4"64(11 e4) MISCELLANEOUS APPLICATION I hereby a cert that I have a certificate of consent tself 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 L.oWEV" A-Z%4gpi, iZJ>, LOCALIT ADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST department CltLOWev OSB ST Date Applicant NEARKST DISTRICT NO T OROUP TYPB CESSED BY CROSS ST �D Q CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL O COMPENSATION INSURANCE DESCRIPTION I LOT NO BLOCK MAP NIGHWAY STATE MAJOR SECOND LOCAL NO OF NO (CIRCLE) (This section need not be completed If the work Involved TRACT NOW ON LOTS USE ZONB SPK CIAL CONDITIONS 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 DWNKR c hen ® y so aOt s to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP a Date ApplicantADDRESS , 66414 CC3 W NOTICE TO APPLICANT If after making this Certificate of CITY lid► NOL 3 Jt' "'3 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 USKGEOLOGY INSPECTION deemed revoked ❑ ❑ No Spec Knowl 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 effect nd Professions Code and my license is in full force and SS PARKING REQ D D PROVIDED D SPACES License Number Lic Class 91 SU E-^ 0.•I LIMITED TIME USE Contractor Date DATE OATH EI am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer BIZK of No of INSPECTOR S acting in my professional capacity (Section 7051 Bus- EXISTING BLDG BroRlKa TURK mess and Professions Code) 11 FINAL APPROVAL JJJ PRESENT USK OP BUILDING / 7-4 Lic or Reg No Date HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS C q [yM ,�- ON LOT AND USE •_ y �f y� 1�I j j, r"If "'4215 I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 70315 Busy ness and Professions Code) NO PARKING ❑ 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 LlPROPOSED USK OF, BUILDING I hereby affirm that there is a construction lending agency M 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 `'n PERMIT FEE W 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 upon the above mentioned property for inspection purposes ` SEE REVERSE FOR EXPLANATORY LANGUAGE _ L Signatur Permitta tate Ag WORKEPIM04ENSATION DECLARATION cE s fit sa) MISCELLANEOUS APPLICATION I hereby^affirm cert ica e I have a certificate of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure or �certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING ADDRE86 / E] Certified copy is hereby furnishedDDRESS UILDIN6 LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department CROSS ST Date Applicant NEAREST DISTRICT NO 6,VOUP TYPE 68B6D BY CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL o COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP wlO ww wT STATE MAJOR SECOND LOCAL NO OF NO (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT B USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) USE OF I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG o permit is issued I shall not employ any person many manner OWNER s-71 so as to become subject to the Workers Compensation Laws MAIL G OCCUPANCY GROUP o Date Applicant ADDRESS S u S `j _AAW NOTICE TO APPLICANT If after making this Certificate of CITY D NOL OCCUPANT LOAD H 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 oI this permit shall be TRAILER USE rl GEOLOGY INSPECTION❑ No Spec Know[ deemed revoked � Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 Busy NO OF EXITS ness and Professions Code and my license is in full force and effectPARKING SPACES REQ D D PROVIDED D / � bj A�L `�1 License Number Lic Class t 4 LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM TO SI uR licensed architect or a registered professional engineer SIZE OF NO OF INBPE T acting in my professional capacity (Section 7051 Bus- RX STING BLDG STORIES mess and Professions Code) FINAL APPROVAL t7 �6 !� PRESENT USE OF BUILDING 7 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 Contractors 1� OOOD—OW1 b/ q/97 License Law for the following reason (Section 70315 Busi [t /�{ ness and Professions Code) NO PARKING 0166 1 AM 7:29 0 I as owner of the property will do the work and the SPACER 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 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 DU upon the above me rope for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ermittee Date WORKERS COMPENSATION DECLARATION a CE 675(11 84) MISCELLANEOUS APPLICATION CE 87 I Webaffirm cert that I have certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION In oo r a certificate of Workers rs Compensation Insurance e or a certified copy thereof(Sec 3800 Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILD INS AD ORBSS Certified copy is hereby furnished 9L.8 Q ZU LOCALITY Certified copy is filed with the county building inspection NEAREST department ��s�M�. �' CROSS ST Date Applicant ��i G, v�� DISTRICT NO GROUP CONSTPROCESSED BY CERTIFICATE OF EXEMPTION FROM WORKERSL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO OF BLDGS NO (CIRCLS) (This section need not be completed if the work Involved TRACT NOW ON LOT USE ZONE8P6 CIAL CONDITIONS by the permit is for one hundred dollars ($100) or Less.) USE OF I certify that In the performance of the work for which this SIZE OR LOT EXISTING BLDG permit is issued I shall not employ any person In any mariner OWNER v G'yb/�il/ o so as to become subject to the Workers Compensation Laws 2[� OCCUPANCY GROUP m A ,MAIL DRESS /.773 O Date Applicant 1 uc3� NOTICE TO APPLICANT If after making this Certificate of CrrY_Q R 446WA T — ,'� OCCUPANT LOAD Exemption you should become subject to the Workers APPLICATIO OR EXIT HARDWARE Compensation provisions of the Labor Code you must forth with comply wit$ such provisions or this permit shall be ❑ E] No Spec Know[ deemed revoked TRAILER U86 GEOLOGY GY INSP6 CTION LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO OF EXITS ness and Professions Code and my license is in full force and effect PARKING REq D D PROVIDED L_-J SPACES JJ License Number Lic Class LIMITED TIME USE Contractor Date D ATC CATS FROM To 1 am exempt from the licensing requirements as I am a licensed architect oI a registered professional engineer SIZE OF NO OF INSPECTOR S acting m my professional capacity (Section 7051 Bus 6 TING BLDG STORIES SIGNATURE mess and Professions Code) FINAL APPROVAL Lic or Reg No Date PRESENT USE OF BUILDING HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE 9 8 0 A I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 70315 Busi # • • • * 88 ness and Professions Code) NO PARKING I as owner of the property will do the work and the SPACES PROVIDED • • • • • • 02 structure is not intended or offered for sale (Section 7044 Business and Professions Code) 4 o610-88 CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency ~CAW— 41A,,' C 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 o I certify that I have read this application and state that the PERMIT FEE V CP above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction anj hereby authorize representatives of this County to enter L.TOTAL,FEE n the ab a mentioned property for Inspection purposes a SEE REVERSE rOXTEXPLANATORY LANGUAGE Signature of ermittee Date Q WORKERS COMPENSATION DECLARATION CE 875(2 80) MISCELLANEOUS APPLICATION {� CE 875 �J 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 ❑ Certified copy is hereby furnishedBUILDING LOCALITY ❑ Certified copy is filed with the county building inspection ADDRESS 574 Lower Azusa Road NEAREST t` department LOCALITY T=p1 P- City ICROSSST Date Applicant NEAREST DISTRIC O TYPE PRO SSED BY CROSS ST Tem le Cit Blvd CONST CERTIFICATE OF EXEMPTION FROM WORKERSLEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO 20 BLOCK 9500 MAP HIONwAY NO (CIRCUM) STATE WAJOR SECOND LOCAL }} (This section need not he completed if the work involved TRACT NOW ON LOTS USE ZONE SPECIAL CONDITIONS 0 by the permit is for one hundred dollars ($100) or less) usa OF U I certify that in the performance of the work for which this SIZE OF LOT 195' x 130' EXISTING BLDG C-2 /�_.� V W permit is issued I shall not employ any person in any manner OWNER 0 so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP ADDRESSnmnna 1JJ Date Applicant Cn NOTICE TO APPLICANT If after making this Certificate of cITY Pqrlc ;ROU OCCUPANT LOAD Z Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code yoy must forth with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION deemed revoked Q ❑ No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) NO OF EXITS ❑ 9 �Fommencmg with Section 7000)of Division 3 of the Busi ness and Professions Code and my license is in full force and effect SPACESPARKING REQ D PROVIDED License Number LIc Class LIMITED TIME USE Contractor Date o AT M O ATE ❑ FROM TO I am exempt from the licensing requirements as I am.a licensed architect or a registered professional engineer SIZE OFNO OF INSPECTOR S acting in my professional capacity (Section 7051 Bus EXISTING BLDG .-TORIES SIGNATURE mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL Lie or Reg No Date HOME OWNER BUILDER DECLARATION ON LOOT NO STING USEI USE BUILDINGS I hereby affirm that I am exempt from the Contractors #21 6!i Q g License Law for the following reason (Section 7031 5 Busi • • • • 8 tj Hess and Professions Code) NO PARKING • •�•+•I• • • SPACES PROVIDED t ft ❑ I as owner of the property will do the work and the 1 —8 4 structure is not intended or offered for sale (Section 7044 Business and Professions Code) PROPOSED USE OF BUILDING 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 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 000-1 and hereby authorize representatives of this County to enter ' up the a ove rIlentioned property for inspection p rposes SEE REVERSE FOR EXPLANATO GUAGE ISignature of Permittee a to r WORKERS COMPENSATION DECLARATION CE 875(2 80) MISCELLANEOUS APPLICATION r hereby affirm that I have a certificate of consent to self COUNTY OF LOST ANGELES BUILDING AND SAFETY DIVISION pure or a certificate of Workers Compensation Insurance or certified copy thereof(Sec 3800 Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILD.NO zf ADDRESS ❑ Certified copy is hereby furnished UILD.NG S 9574— LOCALITY A E] certifiedcopy is filed with the county building inspection DRESNEAREST department L2ALIT- Temple City, CA CROSS ST < < Date Applicant EAREST DISTRICT NO 6 OUP TYPE PRO EDJB CROSS ST Tem le Cit Blvd �^�� ,�I_ CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL (/ COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP / FIIOM WAY } ��.L' nD b (e1wc L8) STATE MAJOR SECOND LOCAL CL (This section need not be completed If the work Involved NO OF BL T US ONE SPED IAL CONDITIONS Y P TRACT NOW ON LOT «L`JJJJ by the permit Is for one hundred dollars ($100) or less) USE OF IZE OP LOT EXISTING BLDG 0 I certify that in the performance of the work for which this permit is Issued I shall not employ any person In any manner 000, OW Susan Chen 13 so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP "AD DRESS 1343 Via Del Rey, S Pasade a N Date Applicant Z NOTICE TO APPLICANT If after making this Certificate of V CITY S• Pasadena NO 213-256-3092 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 C] No Spec Knowl ❑ deemed revoked Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 buss ness and Professions Code and my license is.n full force and PARKING effect SPACES REQ D PROVIDED License Number LIc Class LIMITED TIME USE Contractor Date DATE OATH ❑ I am exempt from the licensing requirements as I am m FROM TO licensed architect or a registered professional engineer SIZE OF NO OF INSP CTOR S acting .n my professional capacity (Section 7051 Bus Rx TING BLOO STORIES SI NATUR mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL Lie or Reg No Date medical clinic _ (O HOME OWNER BUILDER DECLARATION No EXISTING BUILDINGS ON LOT AND USE Qn I hereby affirm that I am exempt ffom the Contractors 317 / / License Law for the following reason (Section 7031 5 Bus. O 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) ROPOS6D USE OR BUILDING medical Clln1C; 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 Oce 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 F� ordinances and State laws relating to building construction TOTAL FEE and hereby authorize representatives of this County to enter u�bove men oned pro rty for Ins ection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per ittee !� Date K P r/41g3'3Vb3 } y+ORKERS COMPENSATION DECLARATION 76M444 CE 875(11 841 M ISCELLANE US APPLICATION ms e o affirm that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure or a certificate of Workers Compensation Insurance or �j`'fir a certified copy thereot(Sec 3800 Lab C) U ALJ Policy No Company FOR APPLICANT TO FILL IN BUILDING 7� ADDRESS ` ' Y a/(0 Certified copy is hereby furnished BUDILD ING - Z-51116k zee y ADRESS LOCALITY 1 1 Certified copy is filed with the county building inspection LOCALITYNEAREST department Temple City CROSS ST Date Applicant NEAREST CROSS ST L� Lv D DISTRI DN GRQfIP CONST ITYPECH$SED BY M CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL /�/J1 i COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK NDA► HIGHWAY STATE MAJOR SECOND LOCAL NO OF SLOGS (elRcl.e) (This section need not be completed of the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (5100) or less,) USE OF I I I certify that m the performance of the work for which this SIZE OF LOT EXISTING BLDG permit is issued I shall not employ an} person in any manner OWNER so as to become subject to the Workers Compensation Laws MAILOCCUPANCY GROUP I Date Applicant ADDRESS ,V gpX ;,1-3J- .S. 1CArUFNA �— NOTICE TO APPLICANT If after making this Certificate of X CITY TEL a 1 3v D OCCUPANT LOAD - Exemption you should become subject to the Workers Compensation provisions of the Labor Code you must forth APPLICATION FOR EXIT HARDWARE I with comply with such provisions or this permit shall be TRAILER use GEOLOGY INSPECTION ❑ No Spec Knowl 14 deemed revoked H LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices O1 I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Busi SAFETY PERMIT (LIST ITEMS BH OW) NO OF EXITS ness and Professions Code and my license is in full force and effect PARKING y SPACES REO D = PROVIDED c I I License Number Lic Class LIMITED TIME USE ��11 �l I Contractor Date D AT< DATE W y ( I am exempt from the licensing requirements as I am a PROM TO CIO 1 licensed architect or a registered processional engineer SIZE OF No of INSPECTOR S Z acting m my professional capaciri (Section 7051 Bu$ EXISTING BLDG STORIES SIGTURE m mess and Professions Code) O I PRESENT USE OF BUILDING FINAL APPROVAL U Lic or Reg No Date 1 I HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS 1� ON LOT AND USE de I hereby affirm that I am exempt from the Contractors D I l I License Law for the following reason (Section 70315 Busi- ness usyness and Professions Code) NO PARKING (/ I as owner of the property will do the work and the SPACES PROVIDED NO FEE structure is not intended or offered for sale (Section �p �;ii1 1� GQ I 1 7044 Business and Professions Code) � T WW-00011 -An 448E CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING RW S 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 ' I certify that [ 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 relating to building construction and hereby authorize representatives of this County to enter TOTAL,FEE t upon the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE t Signature of rmittee d Date r ,