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HomeMy Public PortalAbout5336 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 7enn444 *ISC E L LA N EO U S APPLICATION ( I hereby affirm that I have a certificate of consent to self CE 875 11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, ala certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Polis No.—Company BUILDING � � Y P Y FOR APPLICANT TO FILL IN wDDREss Certified copy is hereby furnished. ADDRESS /�� / X21, • x : ADDRESS �ifm 1� v LOCALITY �d ✓ Certified copy is filed with the county building inspection LOCALIT fir" f� n' NEAREST department. Y/�/��� ` 7 �. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. -. ��f�/GI�/`f- CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION Lor NO, BLOCK MAP HIGHWAY NO. F BLDGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF '0 SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this 61 o permit is issued, I shall not employ any person in any manner OWNER `-' so as to become subject to the Workers' Compensation Laws. // OCCUPANCY GROUP O C3 MAIL � F^>I'^J �� ADDRESS 6 Date Applicant U.3 NOTICE TO APPLICANT: If, after making this Certificate of CITY © NO�Ol1J`'�� "V S� 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Know]. deemed revoked. OCCUPANCY INSPECTION ❑ Panic Devices El LICENSED CONTRACTORS DECLARATION 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 fGy effect. PARKING SPACES PROVIDED n�� — SPACES License Number Lia Class ///y�J��/�� A-r ,fjwJ ``°�� V` LIMITED TIME USE 457 Contractor Date - DATE DATE 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). PRESENT USE: FINAL APPROVAL E OF BUILDING ��T1� r�`� V Lic.or Reg..No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS n �'. O FEE ON LOT AND USE v I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- I 0300130-13001 8/14/92 ness and Professions Code): NO.PARKING I, as owner of the property, will do the work and the SPACES PROVIDED 5021 1 AM. 8:03 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 �lt1lA.1 OL—� for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name Lender's AddressPROPOSED MAX. OCC. 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 Statelaw relating to building construction, and hereby authorize r sentatives of this Count to enter TOTAL FEE upon e ab e-mentio pr per for i spection r ses. C / / SEE REVERSE FOR EXPLANATORY LANGUAGE Signature h Permittee Date WORKERS'COMPENSATION DECLARATION 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.) 17 Policy No. Company FOR APPLICANT TO FILL INBUILDING ADDRESS424C ❑ Certified copy is hereby furnished. BUILDING 3. LOCALITY ❑ Certified copy is filed with the county building inspection _� i• NEAREST department. LOCALITY � CRoss sT. Date Applicant RAREST D xv /+ • DISTRICT NO. GR UP TYPE D BY ' CROSS ST. LIQ- � CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION LOT NO. BLOCK COMPENSATION INSURANCE NO. (CIRCLE) STATE MAJOR SECOND LOCAL > NO. OF BLDGS. NO. (CIRCLE) (This section need not-be completed if the work involved TRACT NOW ON LOT USE ZONE rIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. �� o I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER SA so as to become subject to the Workers' Compensation Laws. MAIL /7 OCCUPANCY GROUP 0 w, .- UJ ADDRESS 51,3 3 4 .0 - ^ CL Date Applicant TEL. NOTICE TO APPLICANT: If, after making this Certificate of CITY &0,V A/.2! o. r Cj /' 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.50 ❑ 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 Sof the Busi- !vss and Professions Code, and my license is in full force and PARKING. effect. SPACES REQ'D E:= PROVIDED. tiicense 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). FINAL APPROVAL N� ESENT USE OF BUILDING 'e-3 "y®�t) Lic.or Reg.No. Date v HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE ,2 5 4 4,0 A I hereby affirm that, I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- #'0 0.0 0 8 8 ness and Professions Code): No. PARKING ;' ) SPACES PROVIDED O O O O 0.0 � ❑ I, as owner of the property, will do the,work and the t structure is not intended or offered for sale (Section ' C9,2 1 -8 3 7044, Business and Professions Code). `r- .ROPOSED 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 buil ing construction, TOTAL Fee and hereby a orize representatives of s County to enter upon the a -me�itio ope nspectio put o SEE-REVERSE FOR EXPLANATORY LANGUAGE �j /Y �3 Signature of ee Date WORKERS'COMPENSATION DECLARATION 76M444 CE875 (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 BU ILD9SS ADDRESS ❑ Certified•copy is hereby furnished. L Q uILDiNG OCALITY - ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY ' L� /9 -T CROSS ST. Date Applicant NEAREST /� l� f DISTRICT N GROUP TYPE PROCESSED BY CROSS ST. A,- ���/ CONS - CERTIFICATE OF EXEMPTION FROM WORKERS' LE ST. COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL This section need not be completed if the work involved NO. OF LCT. USE ZONE SPECIAL CONDITIONS CL ( p TRACT NOW ON LOT. by the permit is for one hundred dollars ($100) or less.) USE OF U 512E OF LOT. EXISTING BLDG. � - - I certify that in the performance of the work for which this fe -1= .permit is issued, I shall not employ any person in any manner OWNER 2E 0 so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP _ DDRESS / , ` / � Date Applicant U) 00 �A ® TEL. /�2� _ 3 OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of Iry L `'T/�//7 NO. J 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 beTRAILER USE❑ GEOLOGY 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 ❑ (LISTATEMS 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 REQ'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 SIGNATURE 1neSS and PI'OfeS510IIS Code). PRESENT USE OF BUILDING i(� � �a- FIIVAi APPROVAL _.4 U 1 Lic.or Reg.No. Date— HOME ate T HOME OWNER-BUILDER'DECLARATION NO. of EXISTING BUILDINGS 8 3 6 3 A ON LOT AND USE • 88 I hereby affirm that, I am exempt from the Contractor's # 0 0 0 0 License Law for the following.reason (Section 7031.5, Busi- 0 0 0 0 0 0 to ness and Professions Code): NO. PARKING 0 SPACES PROVIDED 11 I ❑ I, as owner of the property, will do the work and the 21 6-8 2 structure is not intended or offered for sale (Section 7044, Business and Professions Code). ROPOSED USE OF BUILDING 00 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.4 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 r GGvtitititi pon the above-mentioned ,pro�finspection purpose . SEE REVERSE FOR EXPLANATORY LANGUAGE P .- i nature of Permittee Date, WORKERS'COMPENSATION DECLARATION CE8754(2-80) MISCELLANEOUS APPLICATION I herel;y affirm.,, 'hat.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 furnished. "LDING (u.--�3ZO LOCALITY ADDRESS I Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. 'Date ApplicantEAREST (nye( �/ DISTRICT NO. GR UP TYPE P CESSED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 'O� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE). STATE MAJOR SECOND LOCAL a, NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0U by the permit is for one hundred dollars ($100) or less.) USE // SIZE OF LOT � � EXISTING BLDG. G- ' 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 OWNERUe ` U so as to become subject to the Workers' Compensation Laws. ASL (�7 / �j /��j OCCUPANCY GROUP UJ ADDRESSJy/�V �r a � '/ 1 G' Date Applicant EL. Z NOTICE-TO APPLICANT: If, after making this Certificate of ITr �C 7� T No. ��� , ��� 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 deemed revoked. ❑ No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION FANCY INSPECTIO Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) No. of Exlrs 9 (commencing with Section 7000) of Division 3 of.the Busi- ness and Professions Code, and my license is in full force and effect. PARKING: REO'D PROVIDED /� SPACES License Number Lic.'Class V" LIMITED TIME USE Contractor Date DATE o-xp_t 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 - = _ j SIG NATy _ RE _ iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL _ Lic.or Reg.No. Datec4 � d �Z-/8•�/ 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 SPACES PROVIDED G1 I, as owner of the property, will do the work and the b structure is not intended or offered for sale (Section 7044,Business and Professions Code).: ^' PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY V 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 up a abo e-mention d�property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �ignature of Permit_ee Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) M I SC E L LA N EO U S 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 FILL IN BUILDING / ADDRESS ��(Q � /�) Certified copy is hereby furnished. BUILDING �7�/ p 4� (� LOCALITY //_ A D D R E S S k> ,\O I2 I C-�-L ❑ Certified copy is filed with the county building inspection LOCALITYNEAREST department. C', cRoss ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P CESSED BY CROSS ST. ,D� CON;' / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL -44— COMPENSATION INSURANCE DESCRIPTION I 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 ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. r I certify that in the performance of the work for which thisCD permit is issued, I shall not employ any person in any manner OWNER BF I` n Je'r so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ', o ADDRESS C-3 Date Applicant LLI NOTICE TO APPLICANT: If, after making this Certificate ofCITY i C TEL' U.L& ,p,-_-��p OCCUPANT LOAD 0- Exemption, you should become subject to the Workers' j07 0 — Compensation provisions of the Labor Code, you must forth- APPLICATION EXIT HARDWARE: with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY-INSPECTION ❑ No Spec. Knowk ❑ deemed revoked. 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 ness and Professions Code, and my license is in full force and /) �/7 effect. I� V 1� / PARKING REQ D PROVIDED _ SPACES License Number Lic. Class (— LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a R M: O: licensed architect or a registered professional engineer SIZE OF NO. OF *NRE acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES 43 iness and Professions Code). FINAL APPROVAL a D PRESENT USE OF BUILDING _` Lic.or Reg.No. Date C r a C,1� HOME OWNER-BUILDER DECLARATION NO. OF E (STING BUILD NGS No ON LOT AND USE 1 1 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): c4i _ _NO. PARKING r; ?' SPACES PROVIDED I, as owner of the property, will do the work and the 1310pni 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 f for the performance of the work for which this permit is pi issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address I certify that I have r d this application and state that the PERMIT FEE above information is co ect.I agree to comply with all County ISSUANCE FEE ordina and ate 1 ws relating to building construction, and h reby uth ize r presentatives of this County to enter TOTAL, FEE upon t ab e m io ed property for inspection purposes. 0� 1_�) SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur ermittee Date I COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MISCELLANEOUS PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS MP 0508 1204260004 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE.: (626) 285-0488 EXT: LEGAL ID: NO. OF CONST NEW BUILDING ADDRESS: ON FILE SQ. FT STORIES TYPE OCCUP GROUP 5336 ROSEMEAD BL ISTRUCTURE: 1 V-B U SGAB CA 917762211 (ASSESSOR INFORMATION NUMBER: I NEAREST CROSS. STREET: OLIVE 5388-010-001 IEXIST BLDG USE: THOMAS PAGE: 596 GRID: H4 LOCALITY: TEMPLE CITY, Cl I IEXIST OCC GRP: USE ZONE: TENANT: I (ISSUED ON: PROCESSED BY: JBLDGS. NOW ON LOT: VALUATION: 104/26/12 SR OWNER: TEL. NO: IFINAL DATE FINAL BY: CODE: ITSANG, CHIU (626) 450-5089- ILIST ITEMS: IPO BOX 1983 IROSEMEAD CA 91770 IDESCRIPTION OF WORK IRE-CONVERT A STORAGE ROOM BACK TO ITS ORIGINAL CONDITION 1 IOCCUP LOAD EXIST: IREMOVED UNPERMITTED FULL BATHROOM AND COOKING FACILITY 1 APPLICANT: TEL. NO: JOCCUP LOAD NEW: (SAME AS OWNER - IPARKING SPACES REQUIRED: ISPECIAL CONDITIONS: IPARKING SPACES PROVIDED: 1 EXIT HARDWARE: (CONTRACTOR: TEL. NO: I LIMITED TIME USE ISAME AS OWNER - INBR OF EXITS: ' FROM TO LTC. NO FEES PAID APPROVALS DATE INSPECTOR SIGNATURE IFEE DESCRIPTION: QUANTITY: DOM: AMOUNT: I_ ARCHITECT OR ENGINEER: TEL. NO: I (TRAILER USE - 10A PERMIT ISSUANCE 27.80 1 LIC. NO: 101 R/M OCC/USE INSPECT 146.00 ISAFETY PERMIT TOTAL FEES 173.80 I ITEM?. STRUCT. APPROVED I I IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:1 ITEMP. STRUCT. REMOVED 1147H265 I INO. OF FAMILIES: DWELLING UNITS: APT/CONDI STAT CLASS: S I NO 1 I I I I I I SCHOOL WITHIN HAZARDOUS (AIR QUALITY: 1000 FEET MATERIALS NO NO NO EX f PIKE 1 yc (oi� 1 1 I IREPORT ID: DPR267 ROUTE TO: BS0508