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Home My Public Portal About4700 B MILLER DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent tself insure; or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES RUkD.e,or �, ZNG AND SAFETY DIVISION a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN FlCertified copy is hereby furnished. BUILDIG *qW MILL B 1 ADDR ESNLOCALITY Certified copy is filed with the county building inspection LOCALITY T PLf � qp CII MO NEAREST department. CROSS ST. Date Applicant NEAREST ,�/^��j`� �y QQ DIST IC NO. GROUP TYPE P OC ESSED BY CROSS ST. w = OLKA IER Q' CO NST.V CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STA MAJOR SECOND LOCAL NO. OF BLD GS. NO. (CIRCLE) (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 ($100) or less.) USE OF UI certify that in the performance of the work for which this SIZE OL0% EXISTING BLDG. O permit is issued,I shall not employ any person in any manner OWNER Z y so as to become subject to the Workers' Compensation Laws. MAIL ��nn OCCUPANCY GROUP o Date, Applicant ADDRESS +161;� OALPWUd AM Iv— TEL. (at ��—007f OCCUPANT LO D 0" NOTICE TO APPLICANT: If,after makin this Certificate of CIT`4__ MON IF No. �r�- y Exemption, you should become subje t to the Workers' APPLICATION FOR EXIT HARDWARE z Compensation provisions of the Labor ode,you must forth- with comply with such provisions o this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spe . Knowl. LICENSED CONTRACTOR DECLARATION OCCUPANCY INSPECTION Panic evices ❑ I hereby affirm that I am licensed nder provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencing with Section 700 ) of Division 3 of the Busi NO. F EXITS ness and Professions Code,and y license is in full force and effect. VV1�P O� tII� PARKING REq'D PROVIDED Lic. Class License Number QI.PM CrQTE slug, mac, SPACES LIMITED TIME USE Contractor Date DATE DATE FROM: TO: I am exempt from t licensing requirements as I am a licensed architect ora registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my profes 'onal capacity (Section 7051, Bus' EXISTING BLDG. STORIES SIGNATURE iness and Professions ode). PRESENT USE OF BUILDING )4- p(,t WAItEH ,Sll1/�s FINAL APPROVAL Lic.or Reg.No. Date q z3,g sTbt',KttJG dF �R-TIFtC(At. sll,Il FLOWS. HOME OWNE -BUILDER DECLARATION NO. OF EXISTING BUILDINGS NC1 FEE 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. PARKING1_ci-C_,_,^C.I (/ I, as owner of thepropert will do the work and the SPACES PROVIDED structure is not intndd or offered for sale (Section 1'�' '- (- i °'= 7044,Business and Professions Code). I P" CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ^� I hereby affirm that there is a construction lending agency WARINOtlt' 04 for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address 5 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 he y autliprize representatives of this County to enter TOTAL FEE / upon ie bo entioned property purposes. . SEE REVERSE FOR EXPLANATORY LANGUAGE Signaturl of Permittee Date ii WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION I hereby affirm that I ave a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate o Workers'Compensation Insurance,e,or a certified copy thereof( ec.3800,Lab.Q. Policy No. C pany FOR APPLICANT TO FILL IN ADORE BUILDING SS d Certified copy is her by furnished. BUILDING LOCALITY ADDRESS ❑ Certified copy is file with the county building inspection LOCALITY TEMPLE CITY, CA 91780 c.OSS ST. department. Date Appli nt NEAREST DISTRI T III��QQQ Gjjjjjj0 UP TYPE PROCESSED BY .ROSS ST.LOWER AZUSA RD. (�f � CONST.,/ 'fir n CERTIFICATE OF EX MPTION FROM WORKERS' LEGAL COMPENSA ON INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF BLOGS. (This section need not be ompleted if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one undred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. ,�� I certify that in the perform ce of the work for which this permit is issued,I shall not a loy any person in any manner OWNER t "t i OWEN BROS. ENTERPRISES �� v so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ,,� o ADORE Date Applicant S 4265 NORTH BALDWIN AVE.TEL' Lu OCCUPANT LOAD NOTICE TO APPLICANT: If, er making this Certificate of CITY"L MONTE, N UNKNOWN y Exemption, you should becom subject to the Workers' Compensation provisions of the L bor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provislo s oI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTOR DECLARATION OCCUPANCY INSPEC410N Panic Devices I hereby affirm that I am licensed u er provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) o Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my lic nse is in full force andA A -b I�� effect. IVB PARKING REq D PROVIDED SPACES LL�� License Number Lic. Cl ss MILLION TRADING INC. LIMITED TIME USE Contractor Date DATE DATE Elam exempt from the licensing re uirements as I am a licensed architect or a registered ofesSional engineer SIZE OF NO. OF FROM: To: INSPECTOR'S acting in my professional capacity Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE mess and PIofessions Code). PRESENT USE OF BUILDING K OFFICE & WAREHOUS INAL APPROVAL �—` Lic.or Reg.No. D e HOME OWNER-BUILDER DECL ATION. NO. OF EXISTING BUILDINGS E40 FEE ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec 'on 7031.5, Busi- ness usi ness and Professions Code): NO. PARKING SPACES PROVIDEDi.�_F �-' G•oi� I, as owner of the property, will do he work and the structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AG NCY PROPOSED USE OF BUILDING�[ I hereby affirm that there is a constructs n lending agency NOT APPLICABLE. for the performance of the work for winch this permit is D( issued(Sec.3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. / Lender's Address I PERMIT FEE �5' 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 a 5 upon the bove-menti d proper y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE X,JAN 4, 21 Permittee Signature of Date %r WORKL.RS'COMPENSATION DECLARATION 76M444 '° ,�:I CE 875 (2.80) (MISCELLANEOUS APPLICATION {� 1 hereLYr affi rt that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION rJ 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 Bu1LD //f _ }/_ -t d! ADDRESSING AA 4Z4/ G�/�of ❑ Certified copy is hereby furnished. uILDING LOCALITY ADDRESS .VJ\ �Z ❑ Certified copy is filed with the county building inspection ^ NEAREST department. LOCALITYlea)A R7 CROSS ST. Date Applicant EAREST VVVV DIST 1 T N GROUP TYPE / P ESSED BY ' CROSS ST. n� CONST. f/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v((JJ tI COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL } NO. OF BLDGS. ND. (CIRcLE) d (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.) usE of �- SIZE OF LOT i EXISTING BLDG. Cc 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 V so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUPLU ADDRESS&A(m Ln IL C' Date Applicant U) OCCUPANT LOAD z NOTICE TO APPLICANT: If, after making this Certificate of CITY No. Exemption, you should become subject to the Workers' l APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply -with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION deemed revoked. ❑ ❑ No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[� Panic Devices ❑ I hereby affirm that 1 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 [PA:.CES KING.effect. REQ'D PROVIDED License Number Lic.Class LIMITED TIME USE Contractor pate I I DATE DATE ❑ I am exempt from the licensing requirements as 1 am a FROM: To: licensed architect or a registered professional engineer SIZE OF NO. OF i I INSPECTOR'S acting in my professional capacity (Section 7051, Bus- i EXISTING BLDG. � � STORIES \ S URE iness and Professions Code). I FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGSL7 F: 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 f -#="-� =4-f= 1U. -,,:- SPACES rSPACES PROVIDED ' + ,+ _ 1, as owner of the property, will do the work and the _ ii".0,�T1 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 C to r for the performanceof the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. =- �J Lender's Address PERMIT FEE 1 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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .tfl�I X0-3 S of Permittee Date I . WORI BRS'COMPENSATION DECLARATION 7684441 1-84) ` MISCELLANEOUS APPLICATION CE 875I 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.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING L ADDRESS 41700 FICertified copy is hereby furnished. BUILDESSING pp Miller p 8 r� LOCALITY L ADDR FICertified copy is filed with the county building inspection LOCALITY a G� cRoss RAREST department. ?G/n� T Date Applicant NEAREST f� DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. �w�/l2 �}wsA Pp CONST.,/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL r COMPENSATION INSURANCE DESCRIPTION LO7 NO. BLOCK MAP NIGNWAY STATE MAJOR SECOND LOCAL NO. OF BLDGS. NO. CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT IDD EXISTING BLDG. a 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 t "let s' so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADDREssK v l D — J t3 Date Applicant TEL. LU NOTICE TO APPLICANT: If, after making this Certificate of CIT l �T No. �� SZ B 3 OCCUPANT LOAD Z Exemption, you should become subject to the Workers' gppLl ATION 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. ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIO 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 Busl NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING REQ'D 1 PROVIDED SPACES JJ License Number Lic. Class n K LIMITED TIME USE Contractor Date S t/AS I - ' / (, DATE DATE D I am exempt from the licensing requirements as I am a FROM: O: licensed architect or a registered professional engineer SIZE OF �J NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. VV STORIES SIGNATUR iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date )e_ I JQ4 WkA-E O0 514 HOME OWNER-BUILDER DECLARATION NO. OF EXISTI b 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 ❑ 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 WARE SUS 4*41 0491 # &V NO FEE for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. DAM Lender's Name I { { /!y PROPOSED MAX. OCC. ��)�(�)�—��i i}'/ C}j;SI� Lender's Address I certify that I have read this application and state that the PERMIT FEE 271€; y PH 3;r; above information is correct.I agree to comply with all County ISSU�Fl ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOT upon the above-mentioned propwlypr inspection purpose . .SEE REVERSE FOR EXPLANATORY LANGUAGE nae of eer.��Date ! WORKERS'COMPENSATION DECLARATION C 875 t t t eat CMISCELLANEOUS APPLICATION . I s a75 I hereby affirm that I have a certif-caite of consent tself COUNTY OF LOS ANGELES B`UH-DING AND SAFETY DIVISION - a or a certificate oC►Vorke:s'Compensation insurancc e,or - a certified copy thereof(Sec.3800,lab.C.). Policy No. Company FOR APPLICANT TO FILL INBUILD NG JA/ M • ADDR�SS � Sf Oo / O/693k 6— Certified copy is hereby furnished. uuILDING /jam / 1 ��/// ADDRESS -// , LOCALITY !e 1/ / /� /IA_ �I 17 0 ! ❑ Certified copy is tiled with the county building inspection g 'COC ALITY �� NEAREST l��i{I�C' –r VI (A'/- 1 D v department. ( e G G� 7 Q CROsa sT. L f,W-V.,./` Date applicant I-RAREST DIS-RICTNO. GROUP TYPE CES5ED BY CROSS ST. (��l ' 'D�/ CONS j CERTIFICATE OF EXEMPTION FROM WORKERS' i LEGAL o COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK Mwr Nlc Rw car No. (CIRCLC) STATE MAJOR SECOND LOCAL ' NO. OF BLDGS. (This section need not lie completed If the Work involved TRACT NOW ON LOT USE :ONE SPECIAL CONDITIONS by the permit is for one hundred dollars IS100) or less.) I USE OF I :SIZE OF LOT EXISTING SLOG. – I certify that in the performance of :Ile work For which :his I permit is issued. I shall not employ any person in any manner g dwNER so as to become subject to the Workers' Compensation Lacs. X ,AIL - OCCUPANCY GROUP ( Date Applicant -DDR Ess •�q?� Lf/� C�-�zc� NOTICE TO APPLICANT: If,atter making this Certificate of X CITnoLy��- 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 iuch provisions or his hermit illall be ;RAILER USE i� GEOLOGY INSPECTION No Spec. Knowl. El deemed revoked. LICENSED CONTRACTORS DL'CL.►RArION OCCUPANCY INSPECTION B Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter I9 i 9 (commencing with Section 70001 of Division 3 of the Busi- SAFETY PERMIT (LIST ITEMS BELOW No. of EXITS ness and Professions Code.and my license is in full force and - —_ rlfect. PARKING REO'D PROVIDED :w SPA CES License Number_ Lie. Class I LIMITED TIME USE I Contractor Date Dwre DwTt am exempt from 'he licensing requirements is I and a --- -- m ! licensed architect or a registered ;lrofessional an;ineer ;IZE OFuo. of INSPECTOR'S acting in my professional capaciv. i5ection -1);1. Blls- -'(IS-:NG BLZG. aTOR1E3 slG ATURE a iness and Professions Code I. FINAL APPROVAL .RESENT USE OF SIUILDING p Q Lie.or Ree.No.----_--_—_._• Date ___..---_—__-• — � /� �---- HOME OWNER-BUILDER DECLAR.►rIO\ NO. OF EXISTING BUILDINGS �Jr�GT ON LOT AND USE L/`,, –OBOE•E af i,p+ 1 hereby affirm that 1 ani exempt from the Contractor', Li ( cense Law for the following reason ISec:ion -031.:. Busi_ ddd fffr�[/ ness and ProfessionsCodet: Nl?. PARKING CES PROVIDED C 1, as owner at ;ht property. will do the work ind :he Sr'A structure is not intended or offered for :ale -Section t 1044.Bminess and Professions Code I. V a PIIOPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCYr I hereby affirm that there is a construction lending agency 1 ! for the performance of the work for which this permit is — �• issued(Sec.3097,Civ.0. Lender's Naine —____•.__-_—_ PROPOSED MAX. OCC. I-ender's Address I I certify that 1 have read this application and state that talc PERMIT FEE 25•�� • above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State Ian's relating to building construction, and herebv authorize representatives of this County to enter TOTAL FEE 25.00 1` opo ove-menti •d ropertq• Por! spectiun purposes. • I I - bSL'F REVERSE FOR EXPLANATORY LANGUAGE L7 i1 SienarDme ; I I 1 WORI:EItS'('OnIPI:NSAi'ION DECLARATION CE 875(11.84) MISCELLANEOUS APPLICATION ` I hereby affirm that 1 have a certificate of consent self COUNTY OF LOS XNG'EL-ES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers Compensation insurance,or :I certified copy thereof(See.3800,Lab.C.). ' Policy No._——Company— FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. XX ncwess--4700 MILLER DR. #B3 LOCALITY,,. Certified copy is files(with the county building inspection— NEARESToCALITY TEMPLE CITY, CA91 780 . department. X Date_ __Applicant ___ EAREST LOWER AZUSA AVE. D1 C"� }'P CO ST. �° BY CROSS ST. C CERTIFICATE OF EXEMPTION FROM WORKERS' � LEGAL xj C ONiPENSATION INSURANCE: DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPfi CIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF A� SIZE OF LOT EXISTING BLDG. 1 certify that in the performance of the work for which t s c-1 permit is issued, I shall not employ any person in any man elk OWNER Of buildingOWEN BROS ENT. so as to become subject to the Workers' Compensation Lal OCCUPANCY GROUP Oz ADDRESS 4265 N. BALDWIN AVE. P'— Applicant— — L.1 NOTICE l'() APPLICANT: If,after making this Certificate of CITY EL MONTE CA91 72r- 81 8 443 0078 OCCUPANT LOAD N 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. , OCCUPANCY INSPECTION Panic Devices LIC'Ii.NSE •:D CONTRACTORS DECLARATION ❑ 1 herelly affirin that I am licensed under provisions of Chapter ' SAFETY PERMIT� (LIST ITEMS BELOW 9 (commencing with Section 7000) of Division 3 of the sr- NO. OF EXITS ness and Professions Code,and my license is in full force ' effect. Xme of business PARKING REq D PROVIDED License Number._—.__—I.ic. ('lass_ MILLION LACE & TRIM INC. SPACES LIMITED TIME USE Contractor ...__.._._.—____._—Dale _— DATH DATE PROMI TOI 1 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 Lic.or Reg.No. _ ___ ___.__.__—_ Date PRESENT USE OF BUILDING HOME OWNER-IIIIILDE:R DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE ' I hereby affirm that 1 ails exempt from the Contractor's [}[i�li1—illl�i:1 ?`.��';' .•" License Law for the following reason (Section 7031.5, Busi- 4021 j. Pl "A ness and Professions(.ode): NO. PARKING El1, as owner of the property, will do the work and the i SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). C'ONSTRUC-HON LENDING AGENCY PROPOSED USB 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—___._______.--__ — 25.00 I certify that I have read this applicallon and state that the 1 PERMIT FEE above information is correct.I agree(o 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 25.00 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE XXXX /)ec — C• ,,,,��;-,.—Iir•.„•ill'_'__._ ._ I1:1iC ' 1 I 1YORKERS'COJIPEN'SATIONDE•CLARATIONI ICE 75(11-84) MI:SCELLANEOU,.�� APPLICATION usereby affirm that I have a certificate of consent to self nsure. or a certificate of(Porkers'Compensation Insurance.or COUNTY OF LOS ANGELES i3UILDING AND SAFETY DIVISION LJ a certified copy thereof(Sec.3500,Lab.Q. Policy No. Company— I FOR APPLICANTTO FILL IN BUILDING i 7DO Certified copy is hereby furnished. X:J AD DIL R ESS 111 �. yTV T LOCALITY Certified copy is filed with the county building inspection r LOCALITY F /�/� 1 NIj AFtEST department. X7.t ell• 1e Ct : CA I G�1 CIIOSS ST. Date Applicant I NEAREST O1STR 7 NO. G UP TYPE CIESSED BY CROSS ST. i "O ` I ,(J( CONS CERTIFICATE OF EXEMPTION'F_ROM WORKERS' LEGAL o ,J CO\•IPE\SATIGN INSURANCE DESCRIPTION LOT NO. BLOCK P HIGHWAY STATE MAJOR SEr:OND LOCAL !! NO. OF BLDGS. ICIR CLE) (This section need not be completed if the work Involved TRACT NOW ON LOT VSE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) USE OF SIZE OF LOT EXISTING BLDG. a I certify that in the performance of the work for which this e permit is issued. I shall not employ any person in any manneXX OWNER Of building I ` so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP � ADDRESS �vo. Date Applicant -11pp pp u NOTICE TO APPLICANT: If.after making this Certificate of CITY ` �p11 1�, 0 (,� NO lx`�1k�pOCCUPANT LOAD U, Exemption. you should become subject to the Worker, PPL ION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must fortis with comply with such prov.'slons or *Ills permit shall be iTRAILER USEGEOLOGY INSPECTION No Spec. Know!. ❑ deemed revoked. � O IOCCUPANCY INSPECTION i Panic Devices ❑ LLICENSED CON,TRACTORS DECLARATION1 I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencingwith Se;tion 7000) of Division 3 of the BUST- NO. OF EXITS ness and Professions Code.and my Been w is in full force ani, � effect. )'IName Of business RICInIG REOD PROVIDED _ — ;/ACs, License Number —_ Ltc. Class tA VJ L CD ` ' I LIMITED TIME USE: Contractor Date II DATE nn TE �ryor: To: I am exempt from :he licensing reyuiremenfs as I am a licensed architect or a registered professional engineer SIZE of NO. OF rISPE CTO R'S acting m m} processional canaciW (Se,:-.ion11.151. Bus- EXISTING BLDG. STORIES Y I 51G TYRE iness and Professions Code;. I PRESENT USE OF allILDING i'r'1NAL APPROVAL' Lic.or Reg.No.. —Date T4Vi u I = I (lyyt t•(J F �1 HOMEOWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 1 3J C�L'1LI 1-r E - ON LOT AND USE 1 Hereby affirm that 1 am exempt from the Contractor's License Lav for the following reason (Section 7031.5. Busi-' ness and Professions Code I: NO. PARKING I, as owner of :he property. will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 2- 7044,Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LEN'DI\G AGENCY i , I herebv affirm that there is a construction lending a-vency for the performance of Elie work for which this permit is i issued(Sec. 3097,Civ.C.). i Lender's Name ' PROPOSED MAX. OCC. , Lender's Address � PERMIT FEE 25.00 I certify that I have read this application and state that the above information is correct.1 agree to comply with all County ISSUANCE FEE ordinances and State lairs relatins to building construction, and hereby authorize representatives of this County to enter 1 TOTAL FEE 25.00 y upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE XX . XX -3/2,7/1>0 " G Si=nature of Permittee Date ' I It WORKERS'COMPENSATION DECLARATION 76104 CE 875(11.84) MISCELLANEOUS APPLICATION I-hereby affirm that 1 have a certificate of co*sent to self r, insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION , a:%tifled copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN [.8ADDRENGS �Certified copy is hereby furnished. Bu1LDING 4700 MILLER DR%, UNIT B-2 ITYX21 DDRESS Certified copy is tiled with the county building inspection LOCALITY TEMPLE CITY, CA 91780 ST. department. XX Date Applicant NEAREST DISTRICT NO. GROUP 1TTYPE P ESSED BY ' CROSS ST.LQ= d (� i CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL O !!!�// COMPENSATION INSURANCE DESCRIPTIONLOT NO. BLOCK MAP HIGHWAT C NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work Involved TRACT NOW ON S. J ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF �1 SIZE OF LOT 48 000 EXISTING BLDG. O- I certify that in the performance of the work for which this c� permit is issued, I shall not employ any person in any mannelkXOWNER of buildin OWEN BROS. ENT. =' so as to become subject to the Workers'Compensation Laws. MAIL OCCUPANCY GROUP C")ADDRESS P.O. BOX 1467 LAAr Date_, _ applicant 4 SAN CLEMENTE TFL•(714)498-1418OCCUPANT LOAD NOTICE TO APPLICANT: If,after making this Certificate of CITY NO. v_3 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. Know[. E] deemed revoked. LICENSED(bNTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT[j (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 anX effect. Name of business PARKING LOUIS DOORS GARAGE DOOR SPECIALTIES SPACES REq•D PROVIDED I License Number FIRMING Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OP 1 FROM. To. INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date Q HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that 1 :Int exempt from the Contractor's License law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO.PARKING E1, as owner of the property, will do the work and the SPACES PROVIDED 3 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCI'ION LENDING AGENCY PROPOSED USK OF BUILDING RETAIL SALES OF - ! 1 1 hereby affirm that there is a construction lending agency GARAGE DOOR/OPERATORS & MISC. PARTS for the performance of the work for which this permit is t issued(Sec.3097,Civ.Q. � Lender's Name — •—( ' PROPOSED MAX.OCC. Lender's Address _ PERMIT FEE 1 certify fns I have read this applica�0 and state that the _ above information is correct.I agre mply with all County ISSUANCE FEE ordlnances and State laws re building construction, �•. and hereby aut orize repre s of this County to enter TOTAL.FEE 25-00 on to in ty for inspection purpos s. /SEE REVERSE FOR EXPLANATORY LANGUAGE31 ., XX ,r �1