HomeMy Public PortalAbout5610-5618 1/2 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATIONDECLARATION
CE 875 (2 801 MISCELLANEOUS APPLICATION
CE 876
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUIL,DINd AND SAFETY DIVISION
Insure or %,certificate of Workers Compensation Insurance or
a eerti(ied copy thereof(Sec 3800 Lab C)
Policy No _ Company FOR APPLICANT TO FILL IN OUILvINo r e
woowa.s
❑ Certified copy is hereby furnished au aDING p P(DQJ p /:
ll✓pT QLVn LOCALITY
woo R¢ea p tY 4c
Certified copy is filed with the county budding Inspection NEAREST
department LOCALITY CMOs. er
Date Applicant EARe.T I� DISTRICT NO GROUP Trre rwo au¢o BY
CRoss
an /�! / rD / {✓/ �J CONST
CERTIFICATE OF EXEMPTION FROM WORKERSLEGAL
COMPENSATION INSURANCE v.aCRIPT[ON
LOT No eLocx Mor .rwT¢ NwaoR .ecorvo LOCAL
O LOT a
(This section need not be Completed if the work revolved rwwcT NNoow ry Lor USE :orv¢I ar¢cuL CONDITIONS
by the permit is for one hundred dollars ($100) or less)
U6¢ OF 1
91IG OF LOT fixISTINO BLDG �'1 i Q
1 certify that m the performance of the work for which his s 0
permit Is Issued 1 shall not employ any person In any manner N¢R LU
so as to become subject to the Workers Compensation Laws MAIL 'T ^ f-1 /_ OCCUPANCY GROUPLU
Ok
I If
Date Applicant
NOTICE TO APPLICANT If,after making this Certificate oft., CITY 4- ROL Z OCCUPANT LOAD Z
Exemption, you should become subject to the Workersq PLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you must forth
With comply With such provisions or this permit shall be TRAILER USED GEOLOGY INSPECTION
❑ No Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION occurwncY INsrecnon Panic Devices
❑
1 hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Bust no or Exrta
ness and Professions Code and my license Is in full force and
effectPw REO o 1= PwovlO ao
^� r...� SPACES
..
License Number Llc Class b `At/ n
LIMITED TIME USE
Contractor Date owrc DAT.
❑ TO
1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE or NO OF INSPECTOR .
acting In my professional capacity (Section 7051 Bus- EXISTING aLov erowifie Sia r ¢
mess and Profewons Code) RESfiNT USE OF BUILDINGFINAL APPROVAL
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION No eND U5O BUILDINGS 1�
ON LOAND FE
uS¢
I hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 7031 5 Bust f JLUu—
Aa01 3/30191
ness and Professions Code) NO PARKING
.rwca. PRGVIv ev ^ ply c
I as owner of the property well do the work and the U 1 PM 2`1L1
structure is not intended or offered for sale (Section
7044 Business and Professions Code) rMcroseo OR OF BUILDING
CONSTRUCTION LLNDING AGENCY rp ^� I
I hereby affirm that there is a construction lending agency v � W �JpwclJLCo Q
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
Lenders Name PROPOSED MAX OCC
Lender's Address PERMIT PEE
I certify that 1 hase read-this application and state that the
above Information is correct I agree to Lomply with all County ISSUANCE PEE
ordinances and State laws relating to budding Construction TOTAL FEE
and hereby authorize representatives of this County to enter ! r/
Zupyn t a ove mVtl 0)d,,poper
rty for mspect1Dn pur ores SEE REVERSE FOR EXPLANATORY LANGUAGE
✓/Signature of PeUmittee 0 l5ste q�
WORKERS'COMPENSATIONDECLARATION
CE 875 (11 94) M ISCELLANEOUS APPLICATION
CE 876 n
1 hereby a cert that t have a ceCompen of consent to self COUNTY OF LOS ANGELES
BUILDING AND SAFETY DIVISION 'ill
insure, or a certificate of Workers'Compensation Insurance,or .J�
a certified copy thereof(Sec 3800,Lab C)
Policy No Company 0 OR A PLICANT TO FI LL IN BUILDING /_/G. �y mss,
coo ow Sas Cts /,
Certified copy is hereby furnished Suis-DING LOCALITY
ADDRESSN.EQ
� Certified Copy tsFiledwith the county buil dinginspection LouuTY TEMPLE CITY CALIF. 91780 N¢Aww.TIV
department CROSS Sr
Date Applicant n¢wR¢ST DnrwicT no GROUP rrrs cESSED BY
CROS¢ ST BROADWAY& LAS TUNAS DR. � Oo NS
CERTIFICATE OF EXEMPTION FROM WORKERS uawt
COMPENSATION INSURANCE ....,IT 0. LOT no •Loew Nw HIGHWAY
OF SLOGS ErwrE MAJOR SECOND LOCAL
v
nog eIReLE)
(Thu section need not be completed if the work involved TRACT NNoOW ON LOT USE zona SPECIAL CONDITIONS
by the permit Is for one hundred dollars (5100) or less) use or
SIZE OF Lor Ex I.TING BLDG
I Permit
that d, the performance of the work for y ma ilii CINDY SUN
permit is issued, I shall not employ any person in any manner OW NER v
so as to become subject to the Workers' Compensation Laws OCCUPANCY GROUP
ADDRESS 2207 S. ATLANTIC BLVD. t3
Date Applicant NTEREY PARR TSL
uig ,.Q ( 213) 266-022 Lu
NOTICE TO APPLICANT If, after mak ilii Certificate of el No OCCUPANT LOAD in
Exemption, you should become subject to the Workers APPLICATION FOR EXIT HARDWARE z
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 Know]
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 Busy NO or EXITS
ness and Professions Code, and my license is in full force and 1 m� r—
effect w Y t PAwwING REGD � PROVIDED
FRIENDLY NAILS SPwe ES
License Number Lic Class
LIMITED TIME USE
Contractor Date OATS OAT.
I am exempt from the licensing requirements as I am a PXON To
licensed architect or a registered professional engineer SIZE or No or INS
crow S
acting in my professional Capacity (Section 7051, Bus- KXIITING BLDG SrowieS R
mess and Professions Code) .--I NG FINAL APPROVAL
Lic or Reg No Date N 81��+
fifif9lg N. FhMM3ND. MF FfZ CITY CA 91780 IF
HOME OWNER-BUILDER DECLARATION NO or EXISTING BUILDINGS G (I(I(�(� r'I(r
ON LOT AND USE D 'Ir/ 1 000-0001 5/ 5/95
I hereby affirm that I am exempt from the 031 5, Busis 5 w✓� 0312 1 AM 8f 16
License Law for the following reason (Section 7031 5, Bust ,
ness and Professions Code) No PARKING
DI, 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 tending agency FRIENDLY NAILS IS CONDUCTING BUSINESS
for the performance of the work for which this permit uAS A SALON FOR THE MANICURING.
issued(Sec 3097,Civ C)
Lender's Name
PROPOSED MAX Oce
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,
x5zk�= SEE
s of this County to enter TOTAL FEE for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigi [ire of Permittee ate �1
-� WORKERS COMPENSATION DECLARATION 76 878
CE 875 (11 84) MISCELLANEOUS APPLICATION {�
Ll
I hereby affum that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
more, or a&Ut ieute of Wolters'Compensation Insurance,or
a certified c3f�y MerWf(Sec 3800, Lab C)
Policy Na Company SAUILOIna
� FOR APPLICANT TO FILL IN wovReaE
—a-Certified Copus hereby furnished 119% / LOCALI G
�� wvvaEsa
❑ Certified Copy is fled with the county building inspection 0CALITI TW-/r p(� G%ry rv¢wR¢ST
department cw ossa ST
Date Applicant wREer TU/l//►5 D DIg weer a our coHnr PRo sago Hr
CRO.:.T
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE D¢SCRIPT ION LOT No eL..N 'L / hGHWA
nor L1 (cI cLc) arwrE MAJOR eHCOno LOCAL
No of wLDas
(This section need not be completed if the work involved rwwcT now ON Lor USE ZONEarE nwL co rvo morvg
by the permit Is for one hundred dollars IS 100) or leu) uS¢ o
r
SIZE OF LOT gxIgTIN6
I certify that in the performance of the work for which this o
permit is Issued, 1 shall not employ any person many manner soO OWNER (T
so as to became subject to the Workers' Compensation LawsS6�a i Z OSE 9/VP, E OCCUPANCY GROUP o
MAIL
_ wo owesa \ 1 \
Date Applicant L�LI
NOTICE TO APPLICANT If, after making this Certificate of cmc G/r�/ rraoL �,(� OCCUPANT LOAD a
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE
shall Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit all be TRAILER USKGEOLOGY INSPUCTION ❑
deemed revoked E] ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONNir Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter SAwgry PERM6
9 (commencing with Section 7000) of Division 3 of the Busr E] (Liar ITEMS aglow) NO OF EXITS
nes and Professions Code,and my Incense is in full force and A&& APIii
effect PARKIN G
SPACES REQ o rwovlDeD
License Number Lic Clan
Contractor Date ( LIMITED TIME USE GAT`
iii DATE
I am exempt from the licensing requirements as 1 am a ROM
TO
licensed architect or a regstered professional engineer SIZE or No OF Inge CTOR S
acting in my professional capacity (Section 7051, Bus- Sx1aTlna BLDG STORIES sI wruwH
meu and Professions Code) FINAL APPROVAL
11
rR E68NT USC Or BUILDING I
Lic or Reg No Date
HOME OWNER BUILDER DECLARATIONNo ow Ex ISTING BUILDINGS ,IPJ in FEE
ON LOT ANO USE _ ^
I hereby affirm that I am Exempt from the Contractor's
License Law for the following reason (Section 7031 5, Busr 0000-mi9/89
nen and Professions Code) No PARKING
1, as owner of the property, will do the work and the SPACES PROVIDED 55018 1 P" 3:28
structure is not intended or offered for sale (Section
7044,Business and Professions Code) _
CONSTRUCTION LENDING AGENCY ROPGSKD USE or BUILDING
I hereby affirm that there is a constnictnon lending agency
I O
for the performance of the work for which this permit is V,I/Uf, I I2 I8y
Issued(Sec 3097,Cry C) rJ
Lender's Name
PRoroS¢o MAX Dec
Lender's Address O
PERMIT PEE
I certify that 1 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
n the bovngneA Property ins ectmn pure se�
Pr EE REVERSE FOR EXPLANATORY LANGUAGE
Signatur6 of Date
CWORKERS'COMPL.NSATION DECLARATION CE 875 It 1 941 LJ
MISCELLANEOUS APPLICATION {1
CE 875
Thereby 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 FI LL IN BUILDING
ADDRESS
FiCertified copy is hereby furnished uDDeHss D. INa ,! LoeALIrY
D
❑ Certified copy is filed with the county building inspectionLocwury
dl/departFRI
m 7
cwosa a
Date Applicant NEARESTtL, DISTyLc T.ry a Fire rw0 S D BY
CROSS ST T one'
CERTIFICATE OF EXEMPTION FROM WORKERS' LSGwL `
COMPENSATION INSURANCE D6..RIPTION--TL NO BLOCK pOP (cIw CL[) STwT6 MAJOR 56c0 LOCAL
or al.Dos
(Thus section need not be completed If the work involved TRACT Now oN Lor uSH zo NS SreciwL CONDITIONS
lTL
by the permit is for one hundred dollars ($100) or leu) L Von
I certify that in the performance of the work for which this s or Lor Exi.orOF BLDG - o
permit Is Issued, I shall not employ any person in any manner Id DWNER ,[ S 01V
so as to become subject to the Workers' Compensation Laws OMA,. J OCCUPANCY GROUP
Date Applicant t - w
NOTICE TO APPLICANT If, after making this Certificate of CITY NOL 'L�i 16 2 OCCUPANT LOAD s
Exemption, you should become subject to the Workers' 414
APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply wtth such provisions or this permit shall be GEOLOGY IN SrecnoN
deemed revoked TRAILER USE ❑ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION DccUPwwcr INSPBcrIOPanic Devices
N
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (LIST ITEMS BELOW(
9 (commence g with Section 7000) of Division 3 of the Bust- NO or EXITS
ness and Professions Code,and my license is in full force and
effectPw LAKING
Srwc SE AHG D = I rROv.DHD
License Number Lie Class LIMITED TIME USE
Contractor Date DATA CAT.
rpOM
1 am exempt from the licensing requirements as I am a T.
licensed architect or a registered professional engineer I size or No or INSrecTOR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG erowlEa �r .;NATURE
mess and Professions Code) FINAL APPROVAL
may,
Lie or Reg No Date PRESENT USE OF BUILDING (/
HOME OWNER-BUILDER DECLARATION NO OF EX'STING BUILDINGS
ON LOT AND USE
I hereby affum that I am exempt from the Contractor s
License Law for the followmg reason (Section 7031 5, Busr
nes°and Professions Code) NO PARKING
1, as owner of the property, will do the work and the $FACES PROVIDED
structure Is not intended or offered for sale (Section
7044,Busmen and Professions Code)
,
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affum that there is a construction tending agency
for the performance of the work for which this permit is
Issued(Sec 3097,Cry C)
Lender's Name 1 -
PROPOSED MAX OCC
Lender's Address .^T
Q '4
I certify that I have read this application
Fee and state that the \y
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
d hereby authorize representntrves of thu County to enter TOTAL F66
on the above-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
n/n✓ - AI //6,P
IIt Slgnatur f Permittee Date
WORK$RS' COMPENSATIONDECLARATION
CE 875(71 841 MISCELLANEOUS APPLICATION
CE 876 �I
I affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ,IL JII
insureure, 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
ADDR¢es
Q Certified copy Is hereby furnished OpArILDING _ _ a �—
ADOR¢s¢ LOCALITY �`^
Certified copy Is filed with the county building inspectionLOCALITYNEAREST
department cwone sir
Date Applicantwwiar DISTRICT o u TYPE PROCESSED BY
twoea ST i^ cower
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL / '
COMPENSATION INSURANCE DESCRIPTION LOT No BLocK MwP mNwwv
NO OF BLOGS
No (OR<L.J STAY;MAJOR Ri O LOCAL
(THIS SeellOn need AOI be completed If the WOIk involved TRACT NOW ON LOT
OQ¢ 20X¢ RPQCIAL CO NOITIONR
by the permit IS for one hundred dollars ($100) or less) u9E Ow /71�
XIETINa SLOG USE
J CD
I certify that in the performance of the work for which this SIZE OF LOT Q
permit u Issued, I shall not employ any person in any manner oWNRR v
Al
so as to become subject to the Workers Compensation Laws AIL OCCUPANCY GROUP "v s
Date Applicant wOORiwR
U
W
NOTICE TO APPLICANT If, after making this Certificate of elrY A�iCQ.a .riot 3 �('� OCCUPANT LOAD �
Exemption, you should become subject to the Workers APPLICATION FOR EXIT HARDWARE Z
Compensatton provisions of the Labor Code, you must forth- ❑
with comply with such provisions or this permit shall be TRAILER uE¢ GEOLOGY INSPNo Spec Knowl
deemed revoked ¢cnon
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIOn Panic Devices
I hereby affirm that I am hmnsed under provisions of Chapter SAFETY P¢RM ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busy NO OF RXITS
ness and Professions Code,and my license Is in full force and
effect PARKING REG D E= Pw OVIDED
SPACER
License Number Lic Class
LIMITED TIME USE
Contractor Date
F1I am exempt from the licensing requirements as I am a TO
hmnwd architect or a registered professional engineer SIZE orNo o. INSPECTOR ¢
acting in my professional capacity (Section 7051, Bus ;; STING BLOO ¢rowl¢a Ela wruw¢
mess and Professions Code)
LIc or Reg No Date PRESENT uae oP BUILDING
NW AAaeQ II6 FINAL APPROVAL
HOME OWNER-BUILDER DECLARATION NO OF EXurIKG BUILDINGS
ON LOT AND USE
1 hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 70315, Busi-
ness
ustness and Professions Code) No PARKING
0 1, as owner of theproperty, will do the work and the ¢Pwc¢S PROVIDED \_
v\
structure is not intended or offered for sale (Section v
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSWD USE of BUILDING 72M f 12 1. 0 A
1 hereby affirm that [here is a construction lending agency
# • • • • 88
for the performance of the work for which this permit is . . • . . • .
Issued(Sec 3097,Cw C) 0000-88
Lender's Name
PROPOSED MAX OCC
Lender s Address
I certify that I have read this application and state that the PERMIT FEE Q
above information is Correct 1 agree to comply with all County ISSUANCE FEE
Inances and State laws rclating fo budduig construction, F7
d hereby authorize representa[rve f this County to enter TOTAL PGH ,51�5J
on the above-mentu 06rtWr inspection purposes
/ �EE REVERSE FOR EXPLANATORY LANGUAGE
JJZ
Signa[ a of Permittee to
WORKERS COMPENSATION DECLARATION
CE 875 (11 641 MISCELLANEOUS APPLICATION
CE 976
1 hereby affum that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
,Umie, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company e FOR APPLICANT TO FILL IN aDoR 'so
wILDI
Certified copy is hereby furnishedBUILD CALITY
DOR66a Y/3 EC7
V-7-
Certified copy is fded with the county budding inspectionDuuTY NEAREST
department CROSS ST
Date Applicant NEAREST /� �/ r DISTRICT NO U r'P. PRO RCD
CROSS ST A3 u&r/) ZV C ONRT
CERTIFICATE OF EXEMPTION FROM WORKERS' LQaw4 .J
COMPENSATION INSURANCE DESCRIPTION LOT NO el,ocK No Iclecuj arwre Mwiow E¢ o Locwl
No.
OF BLDG•
(Thu section need not be completed if the work involved TRACT NOH ON LOT USE ZONESP
use OP
ACIAL CONDITIONS
by the Permit is for one hundred dollars ($100) or less-)
SIZE or LOT use OP BLDG
I certify that in the performance of the work for which this -
permit is issued, I shall not employ any person in my manner wNQR C - i v y
so as to become subject to the Workers' Compensation Laws MAm OCCUPANCY GROLP' v m
Date Applicant DOReaS d s
NOTICE TO APPLICANT If, after making this Certiflicate of CITY p xol _ -2, OCCUPANT LOAD y
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑
deemed revoked ❑ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby afflrin that I am llcerised under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busr No of EXIT$
ness and Professions Code,and my license is in full force and3 S
effect " ' RED D E= PRoviD QD
SPACES
License Number Lie Class LIMITED TIME USE
Contractor Date .AT. OAT.
1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE ofoI INSPECTOR a
acting m no my professional capacity (Section 7051, Bus- EXISTING BLDG NO IAS Rla wruRE
mess and Professions Code) FINAL APPROVAL
Lie or Reg No Date PRESENT uae of BUILDING FINAL
OWNER-BUILDER DECLARATION no OF EXISTING BUILDINGS
ON LOT AND USE
1 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 ;2071.8A
1, 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) # 88
CONSTRUCTION LENDING AGENCY PROPOSED USE of RUILDING . . . . $ • • V
1 hereby affirm that there Is a construction lending agency Q 9.20-88
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 PCE � O
I certify that 1 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 buddingtL e, ev I
an herebthorize representatives of this County
ty to[o enter TOTAFEE
'1 n thy authorize
ab e-mentio ed property for inspectionpurposes
SEE REVERSE FOR EXPLANATORY LANGUAGE 11
Signa re of Permittee Date
WORKERS COMPENSATION a cert DECLARATION CE 875 MISCELLANEOUS APPLICATION {�
CE 875(1 t a41 LJ
1 hereby111rForaffunncert that I have a certificate of consent to Ulf COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
twzir�or o certificate of Workers Compensation Insurance,or
a certified copy thereof(Sec 3600,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING ?
AOD.E.5 L
Certified copy is hereby furnished Acnwcae 5&fj Louurr .C—I
Certtfied copy is filed with the county budding inspection
LOCALITY N6.REST
department -r cwoaa Ar
Date Applicant ARS Sr ��/oad� DISTRICT rvo o P TYPE Pwoc Aeo a
cwoaa ST TY1M
CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE OESCR IPT CN LOT NO eLOcw li Q Mw, ID Rwwr
(<ucu) STATE MAJOR CGe.)/L.c.L
(Tits section need not be completed if the work involved TwwcT NO OF BLDGS f
P (e14J now On LOT USE zone APEeuL co nDITIONS
by the permit is for one hundred dollars ($I00) or less.) -
Size OF Lor
I certify that at the performance of the work for which this Z o EXuaEISTIOFNG aI.DG
permit is issued, I shall not employ any person many manner V ovrvER S c�D
so as to become subject to the Workers' Compensation Laws AIL OCCUPANCY GROUP a
Date Applicant A DRESS
v
NOTICE TO APPLICANT If, after making this Certificate of CITY no` (F LziyULI
OCCUPANT LOAD
Exemption, you should become subject to the Workers' qpp LIGATION 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 Know]
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY B+SracriOSej
Panic Devices
I hereby affirm that I am beensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Bust SAFETY PKRMI (LIST ITEMS BELOW) NO OF EXITS
ness and Professions Code,and my license u in full force and
effect PARKING wEo o PwoVID EO
SARKIN
License Number Lie Class LIMITED TIME USE
Contractor Date DATA DAY.
El PROM
1 em exempt from the licensing requirements as I am a TO
licensed architect or a registered professional engineer SIZE OF no or INSPECTOR S
acting in my professional rapacity (Section 7051, Bus- EXISTING BL...,.R,. NTORI.. Zj SI .TuwE
mess and Professions Code) /Q� FINAL APPROVAL /
Lie or Reg No Date
PRESENT ueE or BUILDING /y
HONE OWNER-BUILDER DECLARATION No or EXISTING BUILDINGS
on LOT AND USE
1 hereby aRum that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Busi-
ness
usyness and Professions Code) NO PARKING
El1, as owner of the property, will do the work and the SPACES PROVIDED 8
structure is not attended or offered for sale (Section S £j
7044,Business and Professions Code) • 012
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING \
\ ( 1. 1 ,1 -88
1 hereby affirm that there is a construction lending agency i\
for the performance of the work for which this permit u
Issued(Sec 3097,Cry C)
Lender's Name
PROPOSED MAX OCC
Lender s Address
1 certify that 1 have read this application and state that the PERMIT FEE ,
above mformatW is Correct I agree to Comply with all County ISSUANCE FEE
ordinances a tate law lating to buddmg construction,
d hereby or rep tatrves of this County to enter TOTAL FEE
u on thea a-me toned operty for inspection purposes
//— ^�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Sg tore of Permittee Date
- 1. \/
WORKERS'COMPENSATIONDECLARATION 76M444 M ISCELLANEOUS APPLICATION {�
LJ
I hereby a Certificate
that I have a of consent to self CE 875(11 84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers's'Compensation
sation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN eU ILDI NG
ADDRESS-
Certified copy is hereby furnished BUILDING
...Rfis. Q a/G/ p LocwLrtv
department
copy is filed with the county building inspection Lo eA Llry -
NE.RHST
department Cq Oa6 aT
Date Applicant NaARQBT DIaTgICT NO aRfI,UP TYPE O 9880 BY
CR08B 9T O Q t.( CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LaawL (J 1�J
COMPENSATION INSURANCE Dea cRIrTION LOT No -LOCK DHWA
NO (cI CLK) STATE MAJOR BecOND LOCAL
oeLDas
(This sectionNo r on need not be completed if the work involved rRRcr Now On Lor uee ZONE SrecuL CONDITIONS
by the permit is for one hundred dollars (5100) or ten)
USE OF
TI
SIZH OF LOT H%IBTINa 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 OWNER Q a i,IAI 7
so as to become subject to the Workers' Competisauon Laws MAIL /0 , / O OCCUPANCY GROUP o
AD
dr~ Lva
Date Applicant Z3
NOTICE
NOTICE TO APPLICANT If, after making this Certificate of clrr (,� TEL
L92� OCCUPANT LOAD 0_
Exemption, you should become subject to the Workers' qpp LIGATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be ❑ ❑ No Spec Knowl
deemed revoked TRAILER uae GeowaY INSPECTION
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTtoN Panic Devices
I hereby affI that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busy BRPErr PERM ❑ (LIST ITEMS BELOW)
NO Or EXITS
ness and Professions Code, and my license is in full force and IYAmE ��('
effect • SPACES gQOO PROVID QD u
SPRrARKIN
License Number Lic Class 6 pets 1^l' ' LIMITED TIME USE
Contractor Date PAT. DAT.
❑ 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE orno or INSPECTOR e
acting in my professional capacity (Section 7051, Bus- EXISTING SLOG STORIES SIGNATURE
mess and Professions Code) � FINAL APPROVAL
Lic or Reg No Date PR¢aeNT uae oP BUILDING
HOME OWNER-BUILDER DECLARATION No Or EX'STING BUILDINGS MV FF-
ON LOT AND USE
1 hereby affirm that I am exempt from the Contractor's ,
License Law for the following reason (Section 7031 5, Busr _
or-
ness and Profemons Code) NO PARKING M� M-M, 1/ 4/90
El 1, as owner of the property, will do the work and the SPACES PROVIDED _ r
80231 9. 5
structure is not intended or offered for sale (Section 7044,Business and Professions Code) /f/
CONSTRUCTION LENDING AGENCY r.oroaED USE OF
OUILOINO
I hereby affirm that there is a construction lending agency s
for the performance of the work for which this permit is
issued(Sec 3097,Cry C) r ' I I I V/'�
Lender s Name /I
PROr09ED MAX OCC
Lender's Address
PERMIT Ffifi
I certify that I have read this application and sate that the
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to budding Construction,
and hereby author¢e represemairves of this County to enter TOTAL FEE
p the above-mentioned property for inspecuon purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
C44 �Z �z /
4o'-ture of Permittee ate
WORKERS'COMPENSATIONDECLARATION 76 875 CE 875 It i 841 MISCELLANEOUS APPLICATION {1
LI
I hereby Safeco that 1 have a certificate of consent nc 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 wu on¢na �/
Q Certified copy is hereby furnished BUILo me
wpoE¢aS Al � t $L Lo cw err
DCertified copy is filed with the county bu lug inspection LouurY NHAEaST
department �I cw ossa ST
Date Applicant NEAREST DISTRICT No a uP rr P¢ P EaaEO BY cwoae ST /� S / V4183 /-�O� caxYT
CERTIFICATE OF EXEMPTION FRO ORKERS' L¢awL '.
COMPENSATION INSURAN E DESCRIPTION LOT No BLOCKIGHWA
naP
NO OP QLp66 lis a[) STAT/N-1 OR ¢¢CON. L...L
(This section need not be completed If the WOIk involved TRACT TION ON LOT YB[ ZONE BPQ OIw LRCONpIT10 N9
by the permit is for One hundred dol s ($100) or less) I usE or
SIZE OF LOT ExI STING BLDG
I Certify that in the Performance of th work for which this o
permit is issued, I shall not employ any person many manner OWNER ` ='
so as to become subject to the Worke ' Compensation Laws wIL
MOCCUPANCY GROUP o
Dale Applicant ADOREeS a0 S ATL^//Tec B4 ✓ w
NOTICE TO APPLICANT If, after Ing this Certificate of elrr p,�lF 6 Rif k NO
Z OCCUPANT LOA Exemption, you should become subject to the Workers
Compensation provisions of the r Code,you must forth APPLICATION FOR EXIT HARDWARE
with comply with such provisi s or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec owl
deemed revoked
LICENSED CONTRA RS DECLARATION OCCUPANCY INSPECTION [3Panic De CBs
I hereby affirm that 1 am lice d under provisions of Chapter awPerr PERMIT E] (LIST ITEMS e¢Losv)
9 (commencing with Section 000) of Division 3 of the Busy No or XITS
ness and Professions Code, a d my license is in full force and I^
effect 1I Pw RRG R o PROVIDE.
SPACInIN
License Number Lic Class B CcNpLITER
LIMITED TIME USE
Contractor Date PAYS DAY[
1 nm exempt fro the licensing requirements as I am a N
C
licensed archite or a registered professional engineer SIZE OF No OP o INSPECTOR S
acting in my pr fesstonal capacity (Section 7051, Bus" [ziaTING BLDG STORIES SIGNATURE
messand Profe ons Code) FINAL APPROVAL
Lic or Reg No Dte
a �� Pw eSaxr uta oP BUILDING
ROMEO ER-BUILDER DECLARATION - No ��xIS ma QUILpINaS '/� 3NYOG FEE
ON LOT AND USE V
I hereby affu that 1 am exempt from the Contractors '
License Law f the following reason (Section 7031 5, Busr LA GOOD—M01 6/21/9.
ness and Prof ons Code) no PARKING
1, as o net of the property, will do the work and the SPACES PROVIDE. 13373 1 FH12•21Il
strut isnot intended or offered for sale (Section
7044 usmess and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSE. USE OF BUILDING
1 here affirm that there is a construction lending agency
for t performance of the work for which this permit is �s
issue (Sec 3097,Civ C) ) C V
Len i s Name
PROPOSED MAX OCC
Le er s Address
PERMIT PHE
1 tJy that 1 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 PEE
upon the Bove-mentioned pr perty for inspection purposes
L_. �Z ,��-w X74 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Permi� Date
WORKERS'COD4PENSATION DECLARATION
CE 875(71 84) M ISCELLANEOUS APPLICATION
CE e75
I hereby affirm that 1 have a certificate of consent nc 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)
Eu uDIrvG
Policy No -Company FOR APPLICANT TO FILL IN SS �
R¢ (p
Certified copy Is hereby furnished soon can I g 61 6 t osENEAD LO..ORE..
Certified copy K filed with the county bidding inspection LOCALITY NEAREST Ir
department c"OSS ST
Date Apphcant New"E nr DIST"ICT nq o ouP TYPE eenieD eY
c"Ona ST jZ0�}➢ /� O // _� sonar�J
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ✓ (/
COMPENSATION INSURANCE DESCRIPTION LOT No aLOCXMAP )uRCLRI STATE MAJOR n¢conD LOCAL
rv0 OF /LOSS
(THIS section need AOI be completed If the Work involved TRACT NOW ON LOTUBQ ZONA 6P¢CIAL CONDITIONS
by the permit Is for one hundred dollars (SI00) or less) us E or
I certify that in the performance of the work for which this sae oP LOT O exmnrvG BLDG !i
permit a Issued, I shall not employ any person many manner OwN¢n D12 C%I✓� o
so as to become subject to the Workers Compensation Laws iswlL OCCUPANCY GROUP o
wDDRe
Date Apphcant
NOTICE TO APPLICANT If, after making this Certificate of CITY - y,, NoL X,_, L L OCCUPANT LOAD
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code,you must forth A PLICATION FOR EXIT HARDWARE
with comply with such provisions Or this permit Shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busr SAFETY PERMIT E] (CAST ITEMS BELOW)
NO or EXITS
ness and Professions Code,and my license is in full force and
effect PARKING REO D PRO...¢.
License Number Lic Class CeAfLIMITED TIME USE
Contractor Date D.TR DATE
ElI am exempt from the licensing requirements as I am a Q ,D
licensed architect or a registered professional engineer SIZE OF
No oP IrvePecrow S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG SroRIES SIa Arun¢
mess and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING
Lic or Reg No Date //,,
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS Q's'I
ON LOT AND USE
•/�1 uu �'}
I hereby affirm that I am exempt from the Contractor's / t� [J000—0001 7/1S/'i4
License Law for the following reason (Section 7031 5, Busi-
ness and Professions Cade) No PARKING hili 1 AM L8i:l.G
❑ 1, as owner of the property, will do the work and the SPACES PROVIDED
structure u 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 �O
PERMIT Pee
I certify that I have read tlus application and state that the
above information Is correct I agree to comply with all County Is.0 ANCE FEE
' ordinances and State laws relating to building conswction, f0
and hereby authornze representatives of this County to enter TOTAL FEE f
upon theabov m ��ent oned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pe nttee Date
WORKERS'COAfPENSATION DECLARATION 4
CE 876(11 64)
M ISCELLANEOUS APPLICATION
CE 87
I hereby affirm that 1 have a s'CertificateCoen of consent nc self COUNTY OF LOS ANGELES BUI}.DING AND SAFETY DIVISION
metre, or a certSicate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished wo DR SSSt6�� �+�J BLU I-JA0GTcA lj7jt
LOCALITY
0 Certified copy u filed with the county budding inspection LOCALITY NEAREST
department CROSS RT
Date Applicant NEAREST oTVPE r •need civ
CROSS OTO O /{�� CONS
Tr
CERTIFICATE OF EXEMPTION FROM WORKERS' L.aAL Q
COMPENSATION INSURANCE DESCR IPnoR LOT no -LOCK Mw. .....Al Erwre MAJOR .eco NO LOCAL
NO OF LOGO Ic RCL.)
(Thu section need not be completed if the work involved TRACT Now on Lor uee ZONE SPO CIAL CONDITIONS
by the permit is for one hundred dollars (SI00) or less.) u.URXISTrNG LOG
or
S
I certify that m m
the performance of the wont for which this Sae Or LOT o
permit a issued, I shall not employ any person in any manner x
IA
so as to become subject to the Workers' Compensation Laws eewaew OCCUPANCY GROUP ® o
Date Applicant ADI'M BOB 1>e7 S. LA Y/7&9Irw
NOTICE TO APPLICANT If, after making this Certificate of CIT1A4VV r—RE NOL 0-13)366-0�-.�.2- OCCUPANT LOAD y
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE Z
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shall be ❑ ❑ No Spec Knowl
deemed revoked r¢wueR u¢¢ GEOLOGY wneenoN
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that 1 am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busr SAFETY PERMIT ❑ (CART ITEMS aeLow)
No OF EXITS
ness and Professions Code,and my license u in full force and �I
effect /� PARKING Repo -1 PROVIDED �J
License Number Lic Class SPAeee
LIMITED TIME USE
Contractor Date DATA DAT.
❑ 1 am exempt from the licensing requirements as I am a
D
licensed architect or a registered professional engineer SIZE or No oP I]I]I�]-1]i)I]14,SPee Gg
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG ¢roelea SIGNATURq
mess and Professions Code) PRESENT USE OF eulLDlrva /t
FINAL APPROVAL O 31 �[� .
Lic or Reg No Date /
HOME OWNER-BUILDER DECLARATION NO or EXISTING BUILDINGS n i I� I �f'� FEE
ON LOT wrvD CARE v I
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
ElI, 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 affum that there is a constmetton lending agency colwAlakCIAL
for the performance of the work for which this permit ns
issued(Sec 3097,Cry C)
Lender's Name
PROPOSED MAX OCC
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the 0"D
above information is correct 1 agree to comply with all County ISSUANCE FEE
ordinances and State laws ting to budding construction,
and h�thornze re latwcs o this County to enterre latwcs o this County to enter TOTAL FEE p-'C
upo the abovupo the melsti�o�i f spectnon p�osesf spectionpcses
SEE REVERSE FOR EXPLANATORY LANGUAGE
y
Signat of Permittee Da
-WORKERS COMPENSATION a ON DEto of co sen CE 875 MISCELLANEOUS APPLICATION
.- OE e7B(71 Cbl
1`Tirreby affirm that I have a certificate of consent to m¢ COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
msurc, Or a certificate of Workers'Compensation Insurance,or
a mrtt led copy thereof(Sec 3800,Lab C)
Polley Na Company FOR APPLICANT TO FILL IN so Drize
Certified copy u hereby furnished xX SODA ss 16 E MT^P 8L V-1) Loewurr
F1Certified copy u filed with the county budding inspection LOCALITY NEA:EST
department Xx OR OSS R
Date Applicant NEAREST DI T noo UP TYPE P CESSED By
CROSS Sr Dp // corvST0
CERTIrICATE OF EXEMPTION FROM WORKERS' uO. a f7
COMPENSATION INSURANCE D[SC LION LOT no BLOCS
(CIwCLS) STATE NArow SECOND LOCAL
DP
No Or BLoon
(Thu section need not be completed if the work Involved TRACT Nor ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollen ($100) or leas.) USE or
Sizes or Lor EXISTING BLDG L//_9
1 certify that in the performance of the work for which thisIMI
is issued, I shanot employ any person In any manned oBNER of building Ti" i ND S0,✓
so as to become subject to the Workers Compensation LawsNAIL _ OCCUPANCY GROUP
Date Applicant
woo.9 QL .� 7LhN 711 RL- ✓j7
CD
41
NOTICE TO APPLICANT If, after making this Certificate of CITY H9A1r621 /yak/ TIDE L/?_ X61_ O 3,2, OCCUPANT LOAD a
Fxemptson, 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 berw wlL[s USE Gwlaor mSP[enoN El No Spec Knowl
deemed revoked
I ICENSED CONTRAC fORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
I hereby affirm that 1 am licensed under provisions of Chapter
9 (commencing with Section 7000)of Division 3 of the Busy Swr[rr PEBNrr (LIST ITEMS PEED.)
NO Or EXITS
nese and Professions Code, and my license u m full fora a
effect riName of business PARKING REG E= Pwov1OED
License Number Lm Class UTVIQ EUNK C,.Atf ✓T C---R ZvVL SPACES
LIMITED TIME USE
(ontmctor Date DATE DATA
T.
I am exempt from the licensing requirements as I am a PNDN
licensed architect or a registered professional engineer SIZE or NO or INSPEcrow S
acting in my professional capacity (Section 7051, But E%Ienna BLOC Growlu Smnwru wE
mess and Professions Code) FINAL APPROVAL
Lic or Reg No Date PRESENT USE or BUILDING _
CoNpuTr_rk flE771�L_ TKA / V, -V
IIOMI OWNER BUILDER DECLARATION NO Or UXISTINO BUILDINGS
On LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Season 7031 5, Busy
ness and Professions Code) NO PARKING
1, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for We (Section
7044,Business and Professions Code)
CONSTRUCI ION LENDING AGENCY PROPOSED USE or BUILDING
I hereb) affirm that there is a construction lending agencyti o
for the performance of the work for which this permit u
issued(See 3097,Cw C) t—
Lender s Name
PROPOSED MAX Dec
Lender sAddress j
PERMIT FEE 9 nn] -+
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 buildsiig Construction, Y r
and hereby authorae representatives of this County to enter TOTAL FEE 25.001
upon the above mentioned property for inspection purposes P
XX XX
SEE REVERSE FOR EXPLANATORY LANGUAGE
,
Signature of Petnimee Date
110NA1 IiS (Ot•IPI NSA lION Lit(LARATION 76M"4
875" (11 84) M ISCELLANEOUS APPLICATION
I hereby affum that 1 have a Certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
melte or a Lertificale of Workers (ompenution Insurance or
a r.rhfrd ropy thereof(Se, 3800,Lib C) ,L
Pohl) No _- _—(ompmy-- FOR APPLICANT TO FILL IN eul..mna lG/T ��
wOOR6ffy
FiCertdad Lopy Is hLtLby furnished XXwoo saw —10 1 p YYSXWA ,Jd Lou LITY
F1Certified copv 1s filed oulh the county budding inspection LOCALITY IC � p /1 �R. .�T
dep Utnlenl XX � G�'l 'l 1
Dntc---___ _Applu-ml—____ NSAwEST y` DISYMICrny awouP Goner cESS[D ev
Cwaff Sr tAU `Dd
(I R I II I(A l l Of E%EMPI ION 1 ROM WORKERS' LEawL
(O111P1 NSA ZION INSURAN(I D[fcwnnon I LOT No [LOCK N^• '"xw^ STATE MAJOR S[cDnD Lout
NO OF SLOGS xe
jCIw CLAI
(fhN section nml not be comppleled 1f the work involved TRACT Now On LOT USE Eon[ SP[owL CONDITIONS
by the permit N for One hundred dollars ($100) or less) I USE or
SIZE OF LOT IS ..YING BLDG
I Lerhfy that 1n the performanLe of the work for which this
permit 1s Haled, I shill not employ any person in any niumne" ownER of buildinit Ot- C I hoL Lro
v. is to bc,ome st11qul to (tic Workets (umpenution 1los OCCUPANCY GROUP
MAIL f
ADDRESS .Z QD S �'Q_f, L U
D1tL _ _ _ _ _ Applu mt --__-- —
CA.7 I 7- TEL OCCUPANT LOAD N
NO[R I I(1 AI'PI I(ANI If filer nuking the Certificate Of clry o a No 2/.l'_ 26 6-
I xemption, )al should become subject to the Workers APPLICATION FOR EXIT HARDWARE
(ompensabon ptovlaons of the Labor Code you must forth
nith Lomply ndh suL11 pro tuons or this permit shalt be TRAILER USE ❑ asotuaY ums—cy—❑ No Spec KrnoWl El
dee lite([ieookLd
I R I NSI U(ON I RA( IORS DEC LARATION OCCUPANCY INSPECTION [IPan1C Devices
1 hueh) lffrin that 1 am licensed under provulonsof(hapler SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (cnmu
menig with SeLtuln 7000) of Division 3 of the Busy no or ¢KIPS
ness and Prafesuons(Ode and SP1) license Is in full force e
effCLl r1 X Name of business PARKING CESREG D
LIMITED TIME USE Pw ov m[D
I ILLnse Number Iic (lass "L(rzLl^k COM u�Ls Z.vC
<onlnLbn Dale DATA BATA
TO
❑ I Tm exempt from the licensing requirements as I am a
luensed architect or a registered professorial engineer fnE GF No or 1;'PECr°sl��
acting 1n my professional LapaClty (Section 7051 Bus- Ew ATING BLDG O SToeIEe
messand Professions(ode) FINAL APPROVAL
PRESENT USE OF BUILDING
11L or Reg No _ _— __ _—_ Dale
D $ G r
1101111 OWNI R H(Ill DER DLCLARATION ND OF EXISTING BUILDINGS
ON LOT AND OEM
1 hereb) digin thill I un exempt from the Contractor's
I cense I Tw for the lollonmg rcnuIn (ScOnin 7031 5 Bust
ness and ProlessKlns Code) NO PARKING
Elas coiner of dm properly will do the work and the f."c[f PROVIDED 0
uructure Is not Intended or offered for ale (Section
7044 Husmesv and Professions(ode)
(ONSI RU( I ION LLNDING AGLNCY PROPOSED ire[ or eYuolNo OO
1 hereb) affmn that there is a construction lending agency
lot lite performTnLC of the work for nh1Lh this permit is
issued(See 3097 (Iv O . r A i K ,c,
1 ender s N rine
Ll`•M� PROPOSED HAS•Dec
I undo s AJdass _ _ _ _ _ _—_ --_ _—
01 25 .00
1 certify that I hoe rad Inn< apphwuon Ind state that the PERMIT FEZ
tbove Information 11 LOriell I lgrec to compl) ugh all County ISSUANCE FEE
orduancee and State lana relating to budding construction,
` Ind hereby authorve representatives of this County to enter TOTAL FEE 25.00
upon the above mentioned properq for mapCLtion purposes
�CX L Gni SFC RCVERSE COR EXPLANATORY LANGUAGE
XX �
I`,,n,m - - - 1) it 6
\\OR6CR5 CO\IPEVSAT70N DLCL\R iTIO\
CE 875 11 1 B41
1 CE 875 MISCELLANEOUS APPLICATION
�1
I hereby att that E have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING WD S \FCTY DIVISION
mro Lttt r11u1'
suor a lfkate of Workers Compensation Insurance un Insunce or
P� a certified copy thereof(See 3800,fab C)
OD Policy No Company FOR APPLICANT TO FILL INeu1Lo�Nc �/�Q '1'2.wDDw Sn ro
Certified Lops is hereby furnished z BwuD+LO[oSGS V Al �T21,.m LOCALITY
1 Certified copy 1s Ned with the county budding mspe:llon E NEAREST
department Loc ALlrr 7T /r G�T
�TJ"� r-t cwass sr
Date applicant NEAREST DIsrRI r nf�, cwppEeP rrl.a cCS)Eo nr
CROSS SToY /1_ cons
CERTfFIC%TE OF EXEMPTION FROM l\ORKERS LEGA
COMPENSATION INSLR i\CE DELCRIPTL ION LOT Yo SLD CX
YG, t=ISCLFI NATE MAJOR SECOND LDCJL
NO OF BLD6L
(This section need not he completed If the work involved TRACT now ON LOT USE zo Ne SPECIAL co ND1TIONS
by the permit 1s for one hundred Jullars 1S 1110) or leis) uu OP
r SIZE OF LOT an+srlNC BLDG -
I Lertdy that m the 0errornance of •he wmk or ,.Inch his =
permit u awed I shall not emplov any per.on in any manner % DwNew Cil ® '
so as to become subject to the Workers Compensation Lawsz „AIL - OCCUPANCY GROUP c
1
Date >pnhwm wo DRE.. O jrV �V
NOTICE TO 4PPLIC iVT It .liter making his .;enduate lit E =.Tr L (A- TEL
�j��� — n OCCUPANT LOAD
Exemption• you ,hould become subjec[ To the Workers' APPLICAT N FOR EXIT HARDWARE
Compensation provisions ah the Labor Code lou must torrh
I nith Lomply %nh m.h provisions or his Yemm hall bL _wAILaR ase -1 ..OLD., INSIE.- DN _ No Spec Knowl
deemed revoked
LICENSEDI O\TR iC FORS DLCL\R I,FIO\ o<cavwYc- INsvecnDlr lZ panic Devices
I hereby alf[rm that 1 am licensed under}provlstonsot Chanter
j 9 ILommenarle with Section 70001 of Dl.lrton 3 or the Bust, SAFETY PERMIT ILlsr ITE.IS eE Lo.r) No ov E..T.
rless and Protessluns CodL and my liLense u In lull Iurce and -
etfll[ /' PwRNInG R60 D �� •ROv1D 6D
SPsces J
LiLLnse 1qum1h r _ La Class
LIMITED TIME USE
2 l0ntr3Lt0r Date OATS ..TL----
Z
EJ I int L%,nipt •rom hL hLLnvnE -e4uuemen[e is I -in a -- --
: 1 h,ensed archueL or i remstered imiesslond :IILM2: ' IzX DP YD OP In svE c-OR
2
acting In ms prut.stUnal LapaLu I�el ton -all Boa EEIS- YG BL.b .TD w+a] L+GNwTu L
mess and Proteasions(odor FINAL APPROVAL
✓RE]E YT USE OF )UILOIN6 ,_ /f/)-
3 La or RLI! Vo __ _ D111
HOME OWNER BLILDCR DECL iR\1710\ No OF EXISTING BUILDINGS 0�
ON LOT Ano UEI ,l
I herebv Atfum that t im e%empi trout .he ContraLtor, �a
I Litense Lau a
for the llow tu •x
Ing 35011 '}LL ion -Gal _ 8u,1
rless and Prolesssonsl oder NO PaRXmG
ElI, m oq tier of Ile On.pLrty Lal du 111L vorA and he LPACES P"Ov.Oeo
structure a wt intended or olfe ld Ior stie Se,uon
1 7044 Bumn,ss and Protesswns Cader
(ONSTRL CTIO\ 1 LNDI\G ulC\l 'i X PROPOSED Esc OF BUILDING
1 IILrLbv atfurn that there Is a Lon,tru,non lendme aecnLv
1 I for the pert011112nte of the work for w111L11 this pernat u
Luxe Sec 3097 Co, C I ------ _
Lender s Name
PwoPosaD MAX occ
I LnJLr s \ddress
1 - PERMIT PEE •Q
1 Lenity that I have read this application and Sam that the
above information 6LorTect I agree to Lomply ulth all Coun« ISSUANCE FEE
orduun d Sate Eras mla ing to building COMMLtron m
and h v authorize representatsvcs of this Counts• to enter TOTAL Fee 2$.00
1 up hove-men to propert) Wr mspeLtion purpO,Ls
AL RL\ERSE FOR E\PL iV 4TORY LANGUAGE
len 111v 3I.
WORKERS'COMPENSATION DECLARATION 76M444-
CE 876 (11 84) MISCELLANEOUS APPLICATION {1
Ll
I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
.nacre, or a certificate of Workere Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C) /I
Policy No Company FOR APPLICANT TO FILL IN no ow¢....NS: '](010 A�2 m OS co 61 Q
Certified ropy a hereby furwhed XX woos eaea 51010 '19-1010 I� U j �V
LOCALITY �C66 GA I
� dCee�dCpy ofiled with the County budding inspections LOCALITY I (Fl $'0 RMARKST7-t,S TcAnQ$ 'L iS(Do cQ-u
Date Applicant HEARKSr 01:7CT xo :a.,auP TYPE ryg eESs¢DSw
PP CROSS ST S t' (OO O� coNSr L�. G� _ w
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
C L
COMPENSATION INSURANCE o..ewvnoN Lor xo RLoeK MAPIPNwAY STAT¢ MAJOR SECOND LOCAL
(CIRCLE)
xo OF ¢Loa¢ No
Ms section need not be completed if the work involved TRACT xo. on LOT USE ZONE SPECIAL CONDITIONS
by the permit m for one hundred dollars (SI00) or less) uSE or
SIZE of LOT Exi.n Na FLOG
I certify that in the performance of the work for which the o
permit is issued, I shall not employ any person in any manner ow N¢w of buildin ='
so as to become subject to the Workers' Compensation Laws MAIL 1 I OCCUPANCY GROUP
MAIL S rjG l) 2
Date Applicant w
NOTICE TO APPLICANT If,after making this Certificate of CITYnoL I OCCUPANT LOAD a
Exemption, you should become subject to the Workers CATION FOR,;?/:5 ca -EXIT HARDWARE
Compensation provisions of the Labor Code,you most forth-
with Comply with such provcsrons or thin permit shall be TRAILER u G% �L G¢owoY IxSPEerioN
deemed revoked ' ❑ f� 7�/ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION occurwxcY INSPECTION ❑ Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter SAr KTY PORN" ❑ (LUT ITEMS OKLCN)
9 (commencing with Section 7000)of Division 3 of the Busr xo or KKITS
Hess and Professions Code, and my license s in full force an
effect Name of business SPACPARKING ROO D PwoYADED
arwcES
License Number Lic Class I t LIMITED TIME USE
Contractor Dale P.T. P.I T.
1 am exempt from the licensing requirements as I am a wD.I
licensed architect or a registered professronal engineer alas or xo or Irv9SP AkURR S
acting in my professional capacity (Section 7051, Bus- ¢xiertxo FLOG 5 STORIES O
mess and Profesnons Code) FINAL APPROVAL L„
Lic or Reg No Date Pw ESE xT uSE Or BUILDING —
HOME OWNER-BUILDER DECLARATION No or ROASTING NUILDINGS
ON LOT AND usa ✓//c 7 [I�(1(I—I1Q�I1 1/17/".
I hereby affirm that 1 am exempt from the Contractor's
License Law for the following reason (Section 70315, Busi- � 41-99 1 Amin",
nes and Professions Code) NO PARKING
1, as owner of the property, will do the work and the SPACES PROVIDED
structure Is not intended or offered for We (Section
7044,Busmen and Professions Code) t�
CONSTRUCTION LENDING AGENCY - •RorosRD USE or BUILDINGr I n
hereby affirm that there is a Construction lending agency seyji ed 6
for the performance of the work for which this permit s
sated(Sec 3097,Cry C) (71
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
ordmances and State Iasis relating to budding construction,
and hereby author re sentatrves of thu County to enter TOTAL FEE 25.00
upon the oven ed y inspection pu oats.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
r XX
Skinitifre of Pennntec ate
COUNTY OF LOS ANGELES TEMPLE CITY p 0508 MISCELLANEOUS PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS MP 0508 1204250003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID NO OF CONST NEW BUILDING ADDRESS
I ON FILE SQ FT STORIES TYPE OCCUP GROUPI 5610 1/2 ROSEMEAD BL I
I (STRUCTURE 1 V-B U I TEMP CA 917801842
(ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET IAS TUNAS
15367-028-017 IEXIST BLDG USE I THOMAS PAGE 596 GRID H4 UJCALITY TEMPLE CITY Cl
(EXIST OCC GRP USE ZONE
T
I TEST ISSUED ON PROCESSED BY
ICSEUNG/SOV COMPOUNDING PHARMACY BLDGS NOW ON LOT VALUATION 04/25/12 SR
0 L
TOWNER TEL NO
ICANDET PROPERTIES (626) 281-9338-430 S GARFIELD AVE I IF E / FI1�L BY CODE
[LIST ITEMS I /�/�w
ALHAMBRA CA 91801 I y PTION 1OF WORK vj, �`)
REMOVAL OF UNPERMITTED SINK
10
I IOCCUP LOAD EXIST
(APPLICANT TEL NO IOCCUP LOAD NEW
ICHEUNG, PHILIP -
(PARKING SPACES REQUIRED ISPECIAL CONDITIONS
IPARKING SPACES PROVIDED I
I
(EXIT HARDWARE
CONTRACTOR TEL NO I I LIMITED TIME USE
IJ C C C CONSTRUCTION (626) 233-8496- NBR OF EXITS I FROM TO
11100 VALLEY BLVD p 340-8 LIC NO
TEL MONTE, CA 91931 - 404982 FEES PAID
I (APPROVALS DATE INSPECTOR SIGNATURE
IFEE DESCRIPTION QUANTITY UOM AM3UNT I
(ARCHITECT OR ENGINEER TEL NO I ITRAILER USE
I - TOA PERMIT ISSUANCE 27 80
LIC NO J01 R/M GCC/USE INSPECT 146 00 SAFETY PERMIT
TOTAL FEES 173 80
TEMP STRUCT APPROVED
(MAP NO SEWER MAP BOOK PAGE FIRE ZONE CMP I (TEMP STRUCT REMOVED
IND OF FAMILIES DWELLING UNITS APT/COND STAT CLASS I ,
I NO
I SCHOOL WITHIN HAZARDOUS
(AIR QUALITY 1000 FEET MATERIALS
NO NO NO
I � I
I I I I I
I I I I
I I I I
I I I I
I
I I I I
I I I I I
I I I I
I I I I
(REPORT In DPR267 RovTE TO asosoa I I I I
I
WORKLRS (OMPINSAIION UL(LARAtioN _oloa,1imwl, m, MISCELLANEOUS APPLICATION
I hereb) affirm that I hate a LcrtdILJIL (It LomLnl Io sLh COUN I Y OF IOS ANGFLCS BUILDING AND SAFETY DIVISION II
Insure or a Lerullcate of Work,m (OmPLnsauon In+urd1LL II
a certified copy thereof (Sec 1800 Lab C 1
Policy No (ompan) FOR APPUCANT TO FILL IN BUILDING
BUIL ING AD E55 y A11111® Certified LOP) Is hLrLb) lurmshed i7 D p�-V-D LOCALITY
Certified copy Is I tied with the counp butidulE msix Luon arr ZIP
J department �C.� G/7 �9 �d NEAREST
CRC)SSEARE ST
DateAppllLanl SIZE OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY
CONST i
<LRT11 KAll OF LXLMPfION IROM WORAI It's TRACT BLOCK Lor NO (-
•.,1 COMPENSATION INSURAN(L "• "w"w•T l
no' ,cwcL[I STATE MAJOR SECOND LOCAL
(This s oum need not be completed If thL swirl uroulLld ASSESSOR MAP BOOK PAGE PARCEL Ugh LONE SPECIAL CONortIONa r
by OL permit Is dor out hundred dollars 1%1(0)1 LN Ilss l f
I t
1 certify that In the performance of IhL work Inr wht It Ilii, o N R _I Ej'l,n ILVUI Ja E 4L. '
I permit is Issued I shall not emplo) an) poi 011 In an) In umLr
so as to become subject to the WurLers (Imipematiol, Laws AD Es .,,F OCCUPANCY GROUP it
-A-
_ _
tl Date APPhLanl nrr - __ zIP
NOTICE TO APPLICANT If AiLr making thus (Lnilx lie - OCCUPANT LOAD
l of Exemption )DO should become subject to the Workers APPLICATION FOR EXIT HARDWARE
Compensation prosisions of the Labor Code )ou must fnnhwnh
comply with such proualons or [his pl.nnrt +h III bL ueemed TRAILER Ub Ele^GEOLOGY INSPECTION❑ No Spec Knawl ❑
revoked OCCUPANCY INSPECTIONIC
I PanIC DBVIGea ❑
LIC ENSEU CUNTR ACI-ORS ULC I ARAf[ON
1 hemb) affirm that I on licensed undLr pros lsmas of (h IPILr SAFETY PERMIT❑ I LIST ITEMS BELOW, a
J I 9(commencing with Set Non 700n D
)of Dion 1 of thL 2asmess NO OF EXITS
and Professions CodL .nd my license is In lull IUrLC and eOLct Q,¢ yIM�Sy
PARKING RED D D I
PROVIDED D
r License Number Ln ( I I,s
9 I I X T+XA4I C &A/ u1&,eT L6i L SPACES
(ontnuor
LIMITED TIME USE
DATE DATE
El I am exempt from the licensing rl,ywnmenn as I am a FROM TO
licensed architect or a regislerLJ prok%sumel Lngmeo.r
acting in m) prolLs+lundl Lapaul) IsKown 70SI llusinLss SIZE OF No OF WSPECTOR S
�
EXISrINO BLDC SrORIL> SIGNATURE J � and PnJL+,ions C IIJL 1 }�
I LI[ or Reg No UaIL PRESENT USE OFBUILDING FINAL APPROVAL
i
- I HOML OWNI R-BLIII DLR IN l I AR At ION NU OFLxISnNGRUILDINGS
UH LOT AND USE
hereby affirm that 1 im LSLmpl from IhL (onlrTLwl s I ILLn,L
Law for thL fallowing reason 6i i.ton 7011 s IhI,InC,+ and _
1 Professions(Ode) NO PARKING
l ElI as .ns nt.r of lilt. profxn) lull Ju I111Lv„If. Ind flit. SPACES PROVIDEO
struclurt. is not mtendLd or ulloLd fol +alt. (4Lno 17(Ela PROPOSED USE OF BUILDING
Business and Professions COLIC)
C///RO iL
I I CONSTRUCTION I ENDING AGI N( )
I hemby alliin that there is I con+tructiun lutduig IµnL) for
the perlOrmanLL of the stork for sshich Ito% Ixnml Is I+,uLd
I U (Sec 3097 Civ C ) PROPOSED MAX OCC
Lender s Name —_ __ _ X APPLIC T MNTI TEL NO
Lenders Address __ _ ADDRESS
1 certify that I have read IhD appIILation and slut. Ihd the
above Information Is correct I agree to comply with all County PERMIT FEE
I ordinances and Slate laws relating to budding axDlruLtino and
hereby authorn representatives of this Count) to cnILr upon 45SUANCE FEE
1 t bove-mentioned properq for HISPLLtion purpous
v i TOTAL FEE
EXPLANATORY LANGUAGE
888 Alum of firm( ee Dale
A