HomeMy Public PortalAbout10612 OLIVE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION
CE 875 (2-80)
I her,%- , affirm fihat 1 have a certificate of consent to self COUNTY OF LOS ANGELE BUII�� p SAFETY DIVISION
inset a certificate (Workers'Compensation Insurance,or nLOCALITY
LL�y/a certified copy thereof(Sec.3800,Lab.C.)Policy No. CompanyFOR APPLICANT TO FILL INBUILDINGOADRESSCertified copy is hereby furnished. BUILDING �
i ADDRESS �/ L O `
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY ��, CROSS ST.
Date Applicant NEAREST �� RIOT ND. GROUP TYPE.--
CROSS
PR S BY
CROSS ST. r UViry CONST.f�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �j—
DESCRIPTION LOT NO. BLOCK
COMPENSATION INSURANCE MAP /lO�� Ir'xWA; IL
NO. �7C CIRCLE STATE M JOR SECOND LO a
NO. OF BLOGS.
(This Section need not be completed if the work involved i TRACT NOW ON LOT USE zpNE SPECIAL CONDITIONS V
by the permit is for one hundred dollars (5100) or less.) USE of
SIZE OF LOT EXISTING BLDG. �� O
I certify that in the performance of the work for which this C�T�
permit is issued, I shall not employ any person in any manner OWNER `�
so as to become subject to the Workers' Compensation Laws. MAIL � W
G �L� OCCUPANCY GROUP U
Date Applicant
ADDRESS ,/06/7_ Ci 5'7� N
NOTICE TO APPLICANT: If, after making this Certificate of CITYL` C No� If Z—QL/ 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 S ❑
deemed revoked. C1 No Spec. KnOWI. ❑
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTIO 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 Busi-
ness and Professions Code, and my license is in full force and TG LC/!/ ¢ �J �p PARKING.
effect.
SPACES REWD PROVIDED
License Number Lic.Class 4,ffl T aA--' LIMITED TIME USE
Contractor Date DATE OATIE
❑ I am exempt from the licensing requirements as I am a. FROM: To:
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). y� C^
PRESENT USE OF BUILDING
Lic.or Reg.No. Date FINAL APPROVAL 'p
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that- I am exempt from the Contractor's
Lic nse Law for the following reason (Section 7031.5, Busi-
ne s and Professions Code): NO. PARKING
SPACES PROVIDED r3 3 5,2 Fl
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section f 0 0 0 0 7
7044, Business and Professions Code). PROPOSED USE OF BUILDING '
CONSTRUCTION LENDING AGENCY 2 D ° 6 1.00
I hereby affirm that there is a construction lending agency o 0 0 6 ��
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). f 2.09-8C
Lender's Name PROPOSED MAX. OCC.
Lender's Address PERMIT FEE — T
I certify that I have read this application and state that the _
ibove information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction. TOTAL FEE
Ind hereby authorize representatives of this County to enter
Jpon the above-mentioned r .perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
iC J 6��Q
Signature of Permittee Date
' � r
s
A w
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MISCELLANEOUS PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS MP 0508 9705060001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
EGAL I 0. OF CONST NEW BUILDING ADDRESS:
TR: 11290 LT: 6 BL: A SQ. FT STORIES TYPE OCCUP GROUP 10612 OLIVE ST
STRUCTURE: 1 V R3 TEMP CA 917802842
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREED
8585-031-009 EXIST BLDG US THOMAS GRID: C3 TEMPLE CITY
EXIST OCC GRP: USE ZONE:
TENANT: SS ON: -PROCESSED BY: EXPIRES 0 .
DGS. NOW ON LOT: VALUATION: 06/97 TC 05/06/98
0
OWNER: TEL. NO: FINAL TE INAL BY: CODE:
EMERY LEWIS J;MARLANE M (000) 000-0000- LIST ITEMS: ,7
10612 OLIVE ST
TEMP 917802842 / DEFSCR F WORK- •
TO PERM
I ISTING ADDITION OF BEDROOM AND STUDY 39 S FT
OCCUP LOAD EXIST:
APPLICANT: TEL. NO: OCCUP LOAD NEW:
SAME AS OWNER - -
PARKING SPACES REQUIRED: TjnNS
PARKING SPACES PROVIDED:,__
EXIT HARDWARE _
CONTRACTOR: TEL. N5: _ �a .; LIMITED TIME USE
SAME AS OWNER - NBR OF EXITS` - i� _ FROM TO
LIC. NO
ES A D
�' �A * r APPROVALS DATE INSPECTOR SIGNATURE
FEE DES'CRIP`PIONe „ r! QUANTITY:'UUM:;- "AMOUNT:
ARCHITECT 0 ENGINEER: TE O: :' ' •4 "_ : -- - �, IN fR LER S
OA PERMIT ISSUANCE 27.75
LIC. N0: 01 RMOCC/USE INSPECT 145.95 SAFETY PERMIT
_ TOTAL FEES ' 173.70
TEMP. STRUCT. APPROVED
MAP N0: SEWER MAP BOOK: PAGE: FIRE 'LONE: CMPs , ,` TEMP. STRUCT. REMOVED
0. OF FAMILIES: FEEING UNITS: APT CO D: STAT CLASS:
NO i 2.
SCHOOL HI HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS 'f
NO NO NO
REQUIRED 0 AL SETBACK RO ST
SET BACK YARD: HWY: PROP LINE: WIDTH:
FRONT PL- A �-
SIDE PL-
REPORT ID: DPR267 ROUTE TO: BS0508