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Home My Public Portal About9584 LOWER AZUSA RD_Miscellaneous__ WORKEtS COMPENSATION DECLARATION M ISCELLANEOUS APPLICATION CE 875 I hereby affirm that CE 875(11 84)at I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFE Y 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 9584 Lower Azusa Rd DDR ESS LOCALITY Certified copy is filed with the county building inspection department LOCALITY Temple City, CA 91802 CR sT Date Applicant NEAREST DISTRICT 1�Q G O P TYPE PROCESS D Y CROSS ST �Xi CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL u COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP A HIGHWAY NO //�, (CIRCLE) STATE MAJOR SECOND CAL NO OF BLDGS (This section need not be completed if the work involved TRACT NOW ON LOT USE tOINM SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) USE OF n I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG permit is issued I shall not employ any person in any manner owNER Mrs Susan W Chen y so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP F3T] CD� Date Applicant DDRESS p 0 Box 6694 NOTICE TO APPLICANT If after making this Certificate of V CITY Alhambra, CA 9180PoL (213)256-3092 OCCUPANT LOAD y Exemption you should become subject to the Workers z Compensation provisions of the Labor Code you must forth APPLICATION FOR EXIT HARDWARE with comply with such provisions oI this permit shall be TRAILER USEGEOLOGY INSPECTION a deemed revoked ❑ E] No Spec Knowl 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 REO D D PROVIDED O SPACES License Number Lic Class LIMITED TIME USE Contractor Date DATE DA TE I am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer SIZE OF No cF INSPECTOR S acting in my professional capacity (Section 7051 Bus (STING BLDG STORIES SIG TURF mess and Professions Code) FINAL APPROVAL Lic or Reg No Date PR BSENT USE OF 9UILDINGh--"— Cosme`to g! Hair Cut ) HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 70315 Busi 8 2 2 7 A ness and Professions Code) NO PARKING ❑ I as owner of the property will do the work and the SPACES PROVIDED # • • • • 88 structure is not intended or offered for sale (Section • • • • • • • 7044 Business and Professions Code) I a 2 8_8 7 CONSTRUCTION LENDING AGENCY PROPOSED USE OR BUILDING I hereby affirm that there is a construction lending agency & Permanent) Hair Cu `_ p for the performance of the work for which this permit is hN,1 0� issued(Sec 3097 Civ C) l Lender s Name PROPOSED MAX OCC Lender s Address 1 certify that I have read this application and state that the PERMIT FEE ,Oa 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 on the above ntioned property fo spec purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Si re of Permit Da et WORKERS COMPENSATION DECLARATION CE 875(2 80) MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent self 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) Policy No Company FOR APPLICANT TO FILL IN BUILDING ADDRESS /G� Certified copy is hereby furnished ILDING LOCALITY '�^ aDRESS / � o Certified copy is filed with the county building inspection NEAREST department LOCALITY CROSS ST Date Applicant NEAREST DISTRICT NO G UP TYPE PROC+SSEm BV CROSS ST CONS CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY No C�O (CIRCLE) STATE MAJOR SECOND LOCAL d P TRACT NOW ONNO OF S O (This section need not be completed if the work urvolved 7 USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less) V� uSE OF 3 ZE OP LOT EXISTING BLDG I certify that in the performance of the work for which this C O O permit u issued 1 shall not employ any person in any manner WNER I— so as to become subject to the Workers Compensation Laws AIL _ e �i��dCY GROUP U IJJ DRESS350 S. Figueroa #350 y Date Applicant L A 90071 NOTICE TO APPLICANT If after making this Certificate of rY NOL Qk3 15AW-60"K 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 USEGEOLGINSPECTION deemed revoked � GEOLOGY PC ❑ 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 (commencing with Section 7000)of Division 3 of the Bust ness and Professions Code and my license is in full force and PARKING effect SPACES REO D C� PROVIDED License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM TO I: architect or a registered professional engineer SIZE OF NO OF INSPECTOR S acting in my professional capacity (Section 7051 BUS 1JXISTING BLDG STORIES SIGNATURE iness and Professions Code) ( RESENTFINAL APPROVAL USE OF BUILDING Lic or Reg No Date HOME OWNER BUILDER DECLARATION No EXISTING BUILDINGS ON LOO T AND USE I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Bust ness and Professions Code) NO PARKING SPACES PROVIDED I as owner of the property will do the work and the 9 01 a 3 A structure is not intended or offered for sale (Section 7044 Business and Professions Code) E # 0 0 0 040 ROPOSD USE OF BUILDING CONSTRUCTION LENDING AGENCY Al e 0 0 e 0 a e o� 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 and hereby authorize representatives of this County to enter A ' n the above mentioned property for Inspection purposes SEE REVERSE OR EXPLANATORY LANGUAGE N oKg 1 Signature of P mittee Date 9�