HomeMy Public PortalAbout5614 ROSEMEAD BLVD_Miscellaneous__ ^� L
WORKERS'COMPENSATION DECLARATION'
CE B76 (11 e4) M ISCELLANEOtJS APPLICATION
CE 876 LJ
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
unsure, or a certitcate of Workers'Compensation Insurance,or
a'certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN vuILDING, . �/
ADDRESS
Certified copy is hereby furnished BUILDINGYJ' 0 e 1 LOCALITY
]•(�
CIf
ert>Fed copy is filed with the county budding inspection AD DRESS NEAREST LocwurY I
department CR099 ST
Date Applicant New R EST �1_(� GIST��,s�N p/�, OU TYPE P eB8fi0 BY
CROSS ST �[tp �f CJ,rr CONST r
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL - 'CJ III����
COMPENSATION INSURANCE I DESCRIPn oN LOT No ELocK HIGHWAY.
MA 1C1 CL`' STATE MAJOR SECOND LOCAL ,
NO OF'GLDGS ND
(This section need not be completed If the work invOlyed TRACT NOW ON LOT VS IONS SPE DIALCONDITIONS
by the permit is for one hundred dollars (3100)'or less) uae of
I certify that m the performance of the work for which this arse of LOT QXI9nND eLoo
permit is issued„I shall not employ any person in any mariner OWNeR
so as to become subject to the Workers' Compensation LawsMAIL 5.�/µ [� O' OCCUPANCY GROUP ' o
ADDREss N. �03(:7alllQ LT v
Date Apphcant p uJ
NOTICE TO APPLICANT If, after making this Certificate of CITY I (-+j eoL 8�p "30 —� OCCUPANT LOAD y
Exemption, you' should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
A PLICATION FOR EXIT HARDWARE J
with comply with such provisions or this permit shall be
deemed revoked TRAILER uae ❑ GEOLOGY INSPECTION E] No Spec Knowl
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION El Panic Devices
I hereby affirm that I am hemsed under provisions of Chapter - - -
9,(Commencing with Section 7000) of Division 3 of the Busy NO
PERMIT E] ' (LIST ITEMS e¢Low) NO OF EXITS
ness and Professions Code,`and my license a M'full force and
effect T S PARKING
aPA C{8 REG D PROVIDID
License Number Lm Clazs
LIMITED TIME USE -
Contractor Date DATE D.T.
I am exempt from the Incensing requirements as I am a - -
T.
licensed architect or a registered professional engmcer SIM of NO OF INSPECTOR 8
acting m my professional Capacity (Section 7051, Bus- aXl_STI_NG GLDG_ STORIES S,Q uR¢
mess and Professions Code) _ A FINAL APPROVAL O // �9
Lnc or Reg No Datek PRESENT ua¢ of BUILDING .7 (b IC.
HOME OWNER-BUILDER DECLARATION No F EXISTING BUILDINGS
I hereby affirm ON LOT AND USE that I am exempt from the Contractor's -
License Law for the following reason (Section 7031 5, Bust
ness and Professions Code) NO PARKING _/}.��'"._ (/ •-• -- • '
SPACES PROVIDED _
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044,Business and Professions Code) -
CONSTRUCTION LENDING AGENCY PROPO... US 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
I certify that 1 have read this application and state that the PERMIT FEE
above information is correct I agree to comply with all County ISSUANCE FEE '' - e
ordinances and State laws relating to building construction,
and hereby authorizerepresenta�jves of this County to enter TOTAL FEE '
upon the above men[eee000ned pro itspection purposes
�EE REVERSE FOR EXPLANATORY LANGUAGE
c
` S re of Permit Date
tl . ,
WORKERS'COMPLNSATIONDECLARATION
CE 875 (]601 MISCELLANEOUS APPLICATION
CE 876
1 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 3600, Lab C)
Policy No Compan), FOR APPLICANT TO FILL IN BU
ILDINO ,
wooa¢SS
❑ Certified copy Is hereby furnished aDiLO"rva LOCALITY
wDDwH•a
❑ Certifiedcopy Is with the county building inspection Dn NEAREST
department LocwLlTr i CROSS ST
DateApplicant EAREST DI.TR"cr .ROUP T B cESSED BY
CROSS Sr CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE DESCRIPTION Lor NO BLOCK """^• arwrc RwaoR SECOND LOCAL y
(This section need not be Completed it the work involvedr¢wDT wow oN�ora USE ZONE SPECIAL CONDITIONS tl
by the permit Is for one hundred dollars ($100) or less) Q
USE OP
SIZE OF LOT Hx ISTINa BLDG
I certify that In the performance of the work for which this /� �
permit a Issued I shall not employ any person In any manner 1VNQR C IMP Su 0
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP L U
ADDRBsa.faO S L LU
Date Applicant CL
NOTICE TO APPLICANT If after making this Certificate of circ TNo
EL=ra 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 or this permit shall be TRAILER USE[_ aQOLOaY INSPECTION NO $ eC Know] ❑
deemed revoked P
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECoON Panic Devices ❑
'.thereby affirm that I am licensed under provisions of Chapter SAPETY PERRY ❑ (LIST ITEMS BELOW) NO of EXITS
commencing with Section 7000)of Div aton 3 of the Bust
and Professions Code, and my license is in full force and PARKING
t
SPACES RBD O O PROVIDED
se Number Lic Class
LIMITED TIME USE
Contractor Date o,rC R,Tg
❑ AOM
I am exempt from the register requirements as I am a TO
I censed architect or a registered professional engineer aix6 OP NO of INaP¢Croe S
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG arORlen SIGNATURE
mess and Professions Code) FINAL APPROVAL /�
SENT USE OI BUILDING O /•/r 4�(/.
LIc or Reg No Date - I '••��G /
HOME OWNER BUILDER DECLARATION NO of EX"ETING 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 Bust
ness and Professions Code) NO PARKING , 6 5 A
F1as owner of the property will,do the work and the SPACES PROVIDED F,01
structure is not Intended or offered for sale (Section $ • • • • 88
7044, Business and Professions Code)
OPOSUD USE OP BUILDING Is It
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a const(ULtIOn lending agencv ar 0 2_8(I
for the performance of the work for which this permit Is '
Issued (Sec 3097 CiV C )
Lender s Name
PRoroe¢D MAX Bee
Lender s Address PERMIT FEE
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 TOTAL FEE
and here y authorve representatives of this County to enter
upon 99above ment ed pr perry for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SI net
of ISI `yey Dete
WORKERS COMPENSATION DECLARATION CE 875 (Z 80I MISCELLANEOUS APPLICATION
CE 876
1 hereby affirm that 1 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 Lob C)
Policy No Company FOR APPLICANT TO FILL IN euILOINa ,�/ _ 1f k
woo Reae ✓G -�`'�—'S�l�
❑ Certified copy is hereby furnished uicoixo
LOCALITY � G
Certified copy IS filed with the county building inspection n¢wR Ear
LoeALlrr /edepartment
CROSS ST
Date Applicant NEAw¢arer No GwouP rYP¢ Ro sa¢o a
CROL �/O f/ CONO
T
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL `
COMPENSATION INSURANCE DESCRIPTION LOT NO BI.00X MAP Zeo� „IG„wAr }
O
no (cIRCLeI STATE MAJOR SECOND LOCAL d
nOP BLDGS
(This section need not be completed d O
mthe work involved TRACT Now ox LOT us¢ :oxe aveciwL corvolnorva U
by the permit is for one hundred dollars ($100) or less) us¢ OF
SIZE OP LOT Ex[STING BLDG Cr
I certify that in the performance of the work for which thisO
permit is issued I shall not employ any person m any manner wxcR O bJl �I1'I 'ePW IV L e I
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP 1 W
ADDR¢ae �' iia/ ST d
Date 3/Applicant H
/
NOTICE TO APPLICANT If after making this Certificate of crcv fy�f �y q CAI. NOL .� .j-// %J 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 useGEOLOGY INSPECTION
deemed revoked ❑ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices ❑
I hereby affirm that I am laensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of the Bust
ness and Professions Code and my license Is in full force and - Pwwwlnc
effect SPA Cgs MEQ o E:= PwovlO¢D
License Number Lin Class
LIMITED TIME USE
Contractor Date DAT. AT.
❑ 1 am exempt from the licensing requirements as I am a Te
licensed architect or a registered professional engineer SIZE OF No OF INSPECTOR S
acting m my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES SIGNATURE
iness and Professions Code) Pw¢S¢Nr uee OP aulLoiNe FINAL APPROVAL
21 jj(
Lw or Reg No Dale
W#S Be VVT Sher
NG
HOMEOWNER BUILDER DECLARATION ND ON LOT ANNDD UuSK BUILDINGS
se
1 hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 7031 5 Bust
NO PARKING
ness and Professions Code) 8 AC 6S PNOV IG ED f 3 9 515 A
❑ 1, as owner of the property will do the work and the # A S S S 4 0
structure Is not intended or offered for sale (Sectio
7044 Business and Professions Code)
PROPOSED USE OF BuuolrvG S S S S S A S
CONSTRUCTION LF NDING AGENCY /la O a 0 4—81
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 )
Lenders Name PROPOSED MAX OCC i
Lender's Address PERMIT FEE
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 laws relating to building construction TOTAL PEE
and hereby authorize representatives of this County to enter
o he above-mentioned�erty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permi tee Date -
WPRKERS'COMPENSATION DECLARATION 78M444
CE 875 (280) MISCELLANEOUS APPLICATION
1 hereby affirm that 1 hese a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure or a certificate of Worken'Compensation Insurance or
a cerilfied copy thereof(Sec 3800 Lab C) A.
Policy No Company FOR APPLICANT TO FILL IN HwUDowLLGetai Na
11 gm
❑ Certified copy is hereby furnished L ObUILO'NO
wnnweae Locwurr
Certified copy is filed with the county budding Inspection01
department LOCALITY new REST
cwoe¢ aT
Data Applicant 119AN EST omrw.C'r a u TYP¢ "N- LB-yC
'CROSS ST S //y /CERTIFICATE OF EXEMPTION FROM WORKERS LEDAL '-(/ l VCOMPENSATION INSURANCE DHscRIPTION LOT rvo ¢Loch '..WAY arwre MwJow wL a
no OP 'CLOGS
(This section need not be completed if the work Involved TRACT Now ON Lor uee zoNE aP¢ciwL eonoiriorva Q
by the permit is for one hundred dollars (SI00) or less)
Y¢H
SIZE OF LOT H%IaTITINa BLOO /
I certify that m the performance of the work for which this Q
permit Is Issued I shell not employ any person in any manner OWNER (~1
so as to become subject to the Workers Compensation Laws �• OCCUPANCY GROUP
DR6a8IQ O S♦ pL • (CL
1)
Dale Applicant _
NOTICE TO APPLICANT If after making this Certificate of CITY woe a OCCUPANT LOAD ?
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth APPLICATION FZ5R EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER use GEOLOGY INSPECTION 0 No Spec Knowl ❑
deemed revoked
LICENSED CONTRACTORS DECLARATION occurancY INSP¢rnoN Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW)
9 (commencing with Section 7000)of Division 3 of the Bu:o no oP EXITS
nese and Professions Code and my license is in full force and PARKING
effect SPACES REDO —1 Pw OYi0..
License Number Lic Class LIMITED TIME USE
Contractor Date owrR Dwra
❑ ROMTO
I em exempt from the register requirements as I am a
licensed architect or a registered professional engineer size oP no OF INSPECTOR a
acting in my professional capacity (Section 7051 Bus- H Snrva OLD!
T oP LOlrva
STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL
REe¢Nuee em
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION ON LOO NO HT AND ND USE BUILDINGS
IN
I hereby affirm that I am exempt from the Contractors
License Lew for the following reason (Section 7031 5 Busi ,
ness and Professions Code) No PARKING
s Ac¢S PROVIDED J„ I
❑ I, as owner of the property well the work and the
structure Is not intended or offered for sale (Section
7044 Business and Professions Code) PRoeo¢eo uSH OP auiLOlne • ` 2 4 5 2 6 A
CONSTRUCTION LENDING AGENCYP # • � • • 8 8
I hereby affirm that there Is a construction lending agency ekIF
for the performance of the work for which this permit Is • • • • • a a
Issued (Sec 3097,Civ C )
Lenders Name PROPOSED MAX Bee
0424x86
Lender s Address PERMIT FEE
I certify that 1 have read this application and state that the IssuwneE PEE
above Information Is correct 1 agree to comply with all County
Ord notices and State laws relating to building construction TOTAL FEE
an hereby author'z repreNntahves of this .only to enter
u he hove men tied p t1 for Ins action pur;On"$I SEE REVERSE FOR EXPLANATORY LANGUAGE
NEW • ft
\r l
Signature f Permute RN
I ' WORKERS'COMPENSATIONDECLARATION 20—ooe�3OPW12/90 MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
i •Dssum or a certificate of wdrken'Compensation Insurance, or
a certified copy thereof(Sed 3800 Lab. C)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
8 atN11LDING ADOREr: AiMRefe
C rafted copy to hereby furmshed
Certified copy is filed with the county budding inspection (— ZIP LDCALITY
ant. ( / /� NEARt9T
caoaert
' Date ' Applicant SIZR OF L NO OF BLDGS NOW ON LOT OiSTMCT ND GROuP TYP[ PROCSfS[D BY d
CER11FICATE OF EXEMPTION FROM WORKERS COf1�
I COMPENSATION INSURANCE TRACT BLOCKLDT NO Kee R WAV U
No 10. STATE MAJOR SECOND L L
(This section need not be completed If the worts Involved ASSESSOR MAP BOOK PAGE PARCEL USCI 20 15 ppeclAL CONDmONa ad
I by the permit is for one hundred dollars (5100) or less.) 0
I certify that in mer the perfotence of the work for which this TEL No
I permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws.s ADOCCUPANCY GROUP
Date Applicant CITY Tip—
NOTICE TO APPLICANT If after making this Certificate OCCUPANT LOAD
of Exemption you should become subject to the Workers APPLICATION FOR
Compensation provisions of the Labor Code.you most forthwith EXIT HARDWARE
comply with such provisions or this permit shall be deemed TRAILER Use El GSOLOGY INS"CTION❑
revoked gc No$pKnowl ❑
LICENSED CONTRACTORS DECLARATION occUPANcv IN Ecriotl Cl Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAt PERMR❑ (LIaT ITEMS BELOW) I�
I 9(commencing with Section 7000)of Division 3 of the Business %jime o l� a No or oche �I ._JI
and Professions Code and my license is In full force and effect
PARKING REO D D PROVIDeD D
License Number Lic Class RAme &� PARKI
I Contractor Date LIMITED TIME USE
i ❑ I am tumpt from the Licensing requirements as I am a DATE
licensed architect or a registered professional engioeer raoM ro DAT
acting in my professional capacity(Section 7051 Business Stu OF No or oRa
and Professlolu Code) IX18T1f'�e1-DG sroRleS w Tune.
Lic cr Reg. No Date "F94E T USE Or BUILDING FINAL APPROVAL
' HOME OWNER-BUILDER DECLARATION NO Or E]Ulrrl G BuiLnlNca
ON LOr AND USS
I hereby affirm that I am eumpt from the Contractor s License
Law for the following reason (Section 70315 Business and
Professions Code) NO PARKING
❑ I as owner of the property will do the work and the SPACES PROYIOEO
structure is not intended or offered for sale(Section 7044 1 Paoroaeia use or SUILDRIG
Business and Professions Code) Q `n
CONSTRUCTION LENDING AGENCY ,WP-LSC.•
I I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3D97, Civ C) PaoPoeeD MAX OCC.
Under s Name I APPLICANT rflNrl TEL NO
Lenders Address AppRVe A'I'f�
I certify that I have read this application and state that the
Shave information is correct I agree to comply with all County mort PMFait:I ordinances and State laws relating to budding construction a d
hereby thong representatives of this County to enter upon niswnce Pec
I •t the abet motionedp�inspection purposes.
_ �, rorAL Tec
J g /
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign cvror Permittee Date
WORKI RS ( 01.114 NSAIION DIII \RAIION ,1'1111 ) MISCELLANEOUS APPLICATION
I befLbl Illlnn tbal I I01L I ((11111(11( Ill IIm,Lnl 11 1111 ( OLIN I ) 01 I OS AN(d I I S 131111 DING AND SAI CI Y DIVISION
UISUre Or I Lertll ICAN. DI Worker, (Ong1L11,Joon MILIA u1 L O1 II
1 LLrulled cop% IhcrLol 14LL WIT I Its ( 1
Pohi.) No (1111111 m\ FOR APPLICAN I TO FILL IBJ BUILDING
® BUILDING ADDRESS ADDRESS
(LrUlud Lope nIILrLb1 JUTIUShed 5610_ �,oSEn.+EP(eD gl„�. evv? e
T _ _ Locnurr
1 erallcd cape Is IdLJ ,Loh Ih11011
L 11\ bmldlm p n CITY __
m LIIO
dCITY zip �O
ePaflmelll T „Q�� CIA G( Q NEAREST
�'1 l CRO55 ST
Date _ \ppIIL Illi SIZE OF LOT NO OF BLOGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY
CONST
( l RIII I( All OI I A JONMPIION 1 ROA( \1 uRhl I(` mgcT BLOCK LOT NO 1
r CIMII'LNSAIIUN INSIIR AN( I �.P I....Iw.. (
_ _ STATE MAJOR SECOND LOCAL
a IlhlA Allllllll mcd 11111 Ill lolnPllNd 11 Illi %%(FIN 111\n1\Ld ASSESSOR MAP BOOK — PAGE PARCEL 11SEIONE SPECIALCaNDIT1pN9
b1 IhL PLFIIBI Is lar one hundred 1101111, ISIOU) OI IIS%) _
I LLrld) thn In IhL rxrl UrmmLL nl Ih, LIUrk 101 Nklh IhlsOWN - C(LI �\ S Sunt TEL No __ —_ 1
III J1 ' 1110111 I ,It dl 1110 IIIL \k an) PLl vin III UIN Iu Ionil rV J V —_ L 1
III ILS w buomc 01bµ0 d+ IhL 1101 k1-r, ( onAx nv 111111 I IIIc aDDRE55
S AtLRntT(c gP-V-J, OCCUPANCY GROUP
Dne nK ml a` ep. Rk Cq I t ri
N(lil( h ID \I'I'I IL\NI II 11111m
1 lknu 11111 ( 11111 11 la OCCl1PANT LOAD
of I \0111111011 la11 Should bLL011h ,uhlLLI to ILL \\wkL1s APPt I(,A1IONI tm 1 -- — — ---
(O11111Ln,n NOn pn"Bs1ons of HIL I Ibor( ode Iou must to 111\,1111 LXII HARDWARE
Cll
R\ I
nnpll Nlth VILA N U
hrmisiti1r A /1
(Ills 011111 ,11111 111 LILLInLd TR VI ER J}L Ll GEOLUGYINSPECIIONI No Spec Kllow
l El
OCCUPANCY IN>PECTIONK Panic Devlcas El
I( I NSI I) f ONIR \( H)R S I)I ( I Ali \1 h W
IILrLb) 11111111 till l 1111 hLLIIS&d rIndLI pwu,wlhul ( 111p1u sn1[TV ILRMn I ,l lsl nElAS OElowi a
r 91LOmmlll(l )g "III)SL10un 7111X))UI D1\1sIDn I(11 11% BU InLSs No Or EXITS
U
and PrIALSSIOnS(odL and nl) IICFe Is 1111011 IOILL old IIILLI Lf C,e is ' u1�Sb
PARKING REO D I PROVIDED
I nems Nunlh1-r l It < I nsSPACES
f Th p�N !)i�LR`� SQl_CES q(ZacERt E�
( 'In(' Atilt D1IL LIMITED TIME USE
I El
DATE DATE
I Gill eTempl ieLll the hcLlnn,g nymrunultS 1, 1 Illi a FROM TO
h1-enSeJ mch11e0 ur I reglSlL rue proIL,S1011 d 0101110
1 aLIInF m m) r1IUtL,sland Llnlllll (Al Ll1On 71111 141,InLs1 517E OF NO oI INSPECTORS
E%ISrINP,UI D(
Ind PI1dL,V111A ( UdL) __ IllRll SIGNATURE
Ie or Reg No U BIL PRESENT USE OF BUILDING FINAL APPROVAL
[E*-) Q 1
CL
1 II0hl1 OWNI R RIM DI R DI I. I \li \1 ION 00 or 1 XI 1I Np BIULDIFLI
ON LOT AND USE
I IterLlt) Ilt11m 111 It I ml Lwlgll IIOm I11. (OFF 10oI s 1 ILLnsL
Law for Iht foll,ming 1e,1son (SLI-nun 70111 BIISIIIL, Ind
PfOfesslons (odL I NO PARKING
SPACES PROVIDED
El I 1s ox mr oI thL plOpLlll %%III 1111 IhL oik 11 I the
S111101111111101 mlllldLd O1 0IIL1Ld 1- 1 s111 Itiullou /(111 PRO'Osla USE OF BUR a IN,
BUSIUCII and PIOILSS10111 (odL) - ^ 4a
(ONSIR(I( 11ON I I NDIN(I Aid N( 1 `K
hLnb) dlinn that IhLrL 1S I Lans111101on IUldn1L all.l lo'
Ilse PLOOTTIMLL 01 IIIL Volk for "huh I )1s Ixnn11 IN ssuLd —”
(x1- 1097 (BL ( ) PROP05CDMAX occ
lxndLrs Nallle APPLICANTIAd III TEL NO
Itn11erS Add1LSS X SHO[S1'hft S3.1Yt1kir"o _6(
ADDRESS
I certd) that I haLL aa11 1hrS aPPLL,uum and ,t 111- (h II III, - 1Via, 12,1 A
above Inform IhL
on IS OrrLLI I a(`nL In 1-0111(111 \11111 dl(nllnt) I-ERM.7 FEE 1-'T 4(c��
ordinances and Slate la"s rel nulg to buddlnp LOn,ITnL11o11 and
hereb) aUthorl Ze rLpre,ent unLS nl 11111 (amnl tO Lmll Upnn IswgNCE FEE
the above-1114nrloned pryk I\ fix 111,pL000 11111rh I,Ls
(� 01
1`pY�• LL 1IOTALI rE
a I _ t
X _ SI I RI It I RSI 1 OR 1%11I ANAIOR\ I AN(,(L\61
i
S.Filluke of P" 011Lc ITU
WORKERS COMPENSATION DECLARATION CE 875 (11 Cbl MISCELLANEOUS APPLICATION
CE 876
I hereby a certirm that I have a Certificateaof consent m soh COUNTY OF LOS ANGELES BUILDING ANI) SAFETY DIVISION
Cowie, of a certificate of Workers'(ampensatwn Insurance,or
�I a certified copy thereof(Sec 3800,lab C)
Policy No Company FOR APPLICANT TO FILL IN w.nwcae
Certified Copy is hereby furnished DU ILpING N
wDDw S.S Meaj LOCALITY
Certtfled Copy is filed with the county budding anspection LOCALITY N.ARQ.T
department Temple City CROSS ST
Date Applicant NEAREST DISrR ICT NO aw P TYPE c¢SS¢D DY
cwou ¢r
CERTIFICATE OF EXEMPTION FROM WORKERS'
J L¢aAL J'�COMPENSATION INSURANCE pt SCwvTIoN I LOT No I.L.C. MA. IORw.
(This section need not be Com leted d the work involved TRACT no GP eLDaa
no (.,.CL.) STATE MAJOR SECOND LOCAL
P NOW ON LOT USQ LONA EPQOIAL CONDITIONS
by the pemtrt is for one hundred do8ars (1100) or less.) or
rl
SIZE OF LOT U:%TING BLDG
I certify that in the performance of the work for which this tv
permit is issued, I shall not employ any person in any manner OafN¢R ;
no as to become subject to the Workers' Compensation Laws MAIL ('�A.
A_ OCCUPANCY GROUP
� )
Date Applicant B AD DR¢SSf6�-f /�O9 QW
NOTICE TO APPLICANT If, after making this Certificate of P CITY Ivry Ct rTioL 6 -�g —Do OCCUPANT LOAD
Exemption, you should become or Co to the must
forth-
APP CATION FOR EXIT HARDWARE
i 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 IKSP¢cnOn%t Panic Devices El
I 1 hereby affirm that I am licensed under provisions of Chapter
J 9 (commencing with Section 7000) of Division 3 of the Bust NO PERMIT E] (LIST ITEMS BELOW) NO OP EXITS
ness and Professions Code,and my license is in full force and IiII
effect / PARKING •ROVIp E❑ L-J
License Number aPACKE RED D Lie Class LIMITED TIME USE
Contractor Date OAT. GAT,
1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer viz¢ OF NO oP IN aPecrow S
acting m my professional capacitY (Section 7051, Bus- EXISTING BLDG eroRIE9 W,, ,
mess and Professions Code) FINAL APPROVAL _ A
Lie or Reg No Date PRESENT USE OF BUILDING Z _']
1 N904
HOMEOWNER-BUILDER DECLARAi ION NC O EXISTING BUILDINGS -
ON LOT AND u¢Q
1 hereby affirm that 1 am exempt from the Contractor's r1 X54 O� 1 Ah S 4-
Iy,l License Law for the following reason (Section 7031 5, Bust-
Ben
ustBess and Professions Code) NO PARKING
I, as owner of the properly, will do the work and the SPACKS PROVIDED
structure is not intended or offered for sale (Section
�1 7044,Business and Professions Code)
CONSTRUCf10N LLNDING AGENCY X PROPOSED USE OP BUILDING
1 hereby affirm that there is a wnslmetwit lending agenLy
( ' for the performance of the work for which this permit IS
Issued(Sec 3097,Civ C)
Lender s Name
Lender s Address PROPOSED MAX OCC
") I certify that 1 have read this application and state that the PERMIT FEE 25.00
above information is orrect 1 agree to Comply with all County ISSUANCE FEE
orduunces and State laws relating to budding construction,
and hereby authorize representatives of this County to enter TOTAL FEE 2
_I upon the above ne tsoned property for rasppeet,tioonn purposes25.00
REVERSE 1 OR EXPLANATORY LANGUAGE
s ture of Permittee Date
1 1%ORLERS CO%IPLNSATION DLCL\RATION 75M446 MISCELLANEOUS APPLICATION
'
I hereby at firm that 1 have a Certificate of ,oInsur to Ser CE 875 i 11 841 COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a Lertlhca to of Rorkers Lm
ooev
nuon Inwrame or
a certified Lop3 thereof ISeL 3800 Lab C I
Pohc% No Company FOR APPLICANT TO FILL IN SUILDIS
o owes ��Z /7 b./rlI4
Certified LOP% IL herel)s fUrniSh,u BOUILDR¢.Ne LOCALITY -
AOSf
1 dep raied ment FL Is bled is rth the Lnunn buildingmspeLti°n LOCALITY Temple City crtose sr
Dale kppltwnt NEAREST DISTRICT no ARB rY v¢ E38ED BY
CROSS ST L f CO
CER PIF. O%l OF S kTIO TION FR011'10RLERS Le OAL J G
CO�IPF\S ATI041\$LR\\CE B¢eCwlvnon Lor No aLocR i--110
x
(clRLe) STATE Morrow sBeonB LOCAL
(This Section need not he completed if the fwd involved 1-IAC- No.
0aw onaFeLBaLor use non¢ sveclA LconomONa
by the permit is tot one hundred dollar, IS 100) or less) are¢ OP
SIZL OF LOT CXIf TING BLAB I `-
1 certifs that in the OLrtorman,e of he cork o- shIch his -
so as is ISSuu1 I ,Ball not theemplo%Ao tin ne-wn nam mannv Bwlvew A
w as to be,ume ,u blest o the 1L orkers Co noensauon i a1, x
MAIL OCCUPANC GROUP
I AOORCs6
Date Apnhcanr _
NOTICE TO %PPLIC%NT If ar e• makmL hrs C1n_!1I to a Xt cIT r NEL
-p OCCUP AN- LOAC
ELempuon Lou ,nould hi some,, o hL 1l1rke•1 APOL'CATICN O?F E`c - -'ARC'11aFD
Compensation orm kions or .he Libor ,ide Lou must ior.h
1 sL ith Lomon unh u,li me iLl+m or III, had be I-RAILER as¢ L7OeowrY N<Pec- o. — No Soar: '<10^tI ❑
deemed-„owed
LICENSED CONTR\CTORS DECL%RATION OCCUPANCY INSPE<-ron Panic Devices
J
I Iiereb% arfirm hat I am 'icensed undo-nro%icions or C mote• sAFery PEnMrc G-
9 I,ommenLine 11th SeLaon -0001 of Dntston 3 of .he Butt (LIST Ir¢,1s Be LBLv) NO OF EXITS
Bess and P-ntLssion, Cod, and mL license 1s in ud Force Ind
elfeL. PARKING• R¢OO u •w OV10 CB
f svAces
3 Liun e Numb,r L.c CIA„ G L LIMITED TIME USE
ContraLtor Dat, O..e O•=E
T.
l am exempt from the i,ensine reouvements as 1 am t
m 1 licensed architec• or a registered proteastonal enetneer TINE OF no aF INSPECTOR
z a,unc n m, PrOlLscmnal Ir 1_. SL. ,on 'o;I Bu, Eris Tlva BLBO s-ORIe. SIGNATU e
a mese ant Y•otessi,nc C td,l
O RCSCYT us¢ OF BUILD.Na FINAL APPROVAL {
Lie or Re_^_ No Dr.L
s I _
HO1IE ORNER BLILDER DLCLAR\TION NO OF EXISTING BUILBINaf
ON LOT ANO US6 oul7r-00C 1 Lary '4S
I hereby affum dint I am evempt from Lhe COntciLtOrs °d�l]i 1 Art Bp 7>?
License Lal for the follolmg reason (SeLuon Bust
ness and P-oreasions Code) NO PARKING
I as 1wner 01 the property udl do hL work and the sPwcES Pw oviG eO
strucaire Is not intended or uttered for ,ale .$Lawn
7044 Rusin„s and Professions Code) `
CONSTRLCTION LLNDING %GFNCI X PROPOSED USE OF BUILDING
I h,reb% affirm that there is a ,onstructIon IendmR aeem_% OU 4
for tlx performancL of the stork for whu.h this permit is
i5suLd ISLL 3097 CO. C )
Lender s Name
PROPOSED MAX Dec
Lender s Address
1 I certif} that 1 hale read this application and state that the PERMIT FEE 25,00
abode information is Lorre,t I agrLe ID LOMPI) 11th all County ISSUANCE FEE
ordircri and State laws relating to budding constru,tion
and her orae representatnes of this County to enter TOTAL FEE 25.00
1 upon the atwse nttoned pro pert} for m,peLtton purpose
' I p Zq/SEE REVERSE FOR EXPLANATORY LANGUAGE
/ /
Siltnature of it ate
WORKERS COMPENSATION DECLARATION
CE 875 111 841 MISCELLANEOUS APPLICATION
CE 875
•I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING 4,ND SAFETY DIVISION
insure, or a certilivte of Workeri Compensation Insurance,or
a Certified copy thereof(Sac 3800,Lab C)
�J Policy No Company FOR APPLICANT TO FILL IN BUILDln na
coDR[a
.oS
F1 Certrfled copy is hereby furnished Bu
ow[eSa ILnIN6 N ROSQMFP„J ✓d D CA9 LCALITY
w
I ❑ Certified Copy is filed with the counry budding inspection departmentLOCALITY Temple City cwasI rr
I Date Applicant NEAREST DISTRICT No GROUP TTPE r ESS[O ET
Pp CROs[ ST D
I CERTIFICATE OF EXEMPTION FROM WORKERS' LEawL
�O le CON[
COMPENSATION INSURANCE D[Scw vnON LOT No CLOCK N•P '^"R^• STAT[ MAJOR SECOND LOCAL
no or FLOGS
jmRc .l
flhu section need not be completed If the work involved Tww.T Now ON LOT USE :ON[ SPECIAL CONDrtio NS
by the permit is for one hundred dollars (SI00) or less) uSE or
I certify that in the performance of the wori, for which this aiz[ or LOT It IS BLDG
permit u Issued, I shall no[ emplov Cay person m any manner ornew ® U
so as to become subject to the Workers' Compensation Laws �MAIL I� 7 [� 1�� QO� OCCUPANCY GROUP CD
CD
A!ADORE
I Date Applicant TEL
1 "'
'NOTICE TO APPLICANT If, after making this Certificate or CITY fRrrw � no _ 6G���0 OCCUPANT LOAD
E% mptror you should become subject to the Workers APPLICATION FOR =XIT 4AR D6YARc
Compensation provisions of the Labor Code sou must .orth-
with comply with such provisions or this permit shall be ;TRAILER .,5E — -
GEOLOGY INSP.= ION — O
deemed resoked
^ — — No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY IrvsPEc-ION) Panic Devices
1 hereby at firm that I am licensed under provisions of Chapter SAPET- PERMIT — (LIS- ITEMS s£LOv
/ 9 Icommencim with Section 7000) of Dnision 3 of ,he Busr
ness and Professions Code and ms license u in LB ores ana I
etfec /� �/�' PARXING .Eo o
I SPACE$
License \umber L L Qass
LIMITED TIME USE
I ContmCIOT Date =•T. O•*•
0 1 am exempt Tom .he uuensing •equuements as I am .I
i licensed architec, o• a -egunt al oro,essional enginee• sr:E or rvc OF INSrec-ORs
acting in int proiessional zapa,ui iSe. ton -051 Bur EXISTING auG STORIES $IervaruRE
mess and Professions Lode)
FINAL APPROVAL n-Z _�
rw£SEN- USE Or BVIL7ING
i LIc or Reg No Da,e L
)
HOME OWNER BLILDER DELL%RJ,-10\ NO or EXISTING EVILGING$ M/
ON LOT ANO USE
1 hereby affirm that I am exempt rom the Contmstori.L
License Lau for .hese-
fo0oss Ing reason ISeumn -0315 Bu
r
ness and Professions ..oder NO PARNINa
1 as owner of ,he proper" %sill do ,he work and the SPACES PROVIDED j
structure is not intended or offered tot We ISecnon
7044 Business and Proresnons Cods
CONNSCRLCTIO\ LE\DING AGENCI g PROPOSED USE or aulLmno
1 hereby affum that there Is a Construction lending ageno yr
t I for the performance of the wort for sthiCh this permit Is
Issued(Sec 3097,Civ C I
Lender s Name
PROPOSED MAX Dec
Lenders Address 25.00
CSW�$r$
I I
I veru$ that 1 have road that Epphauon and state that the U
PERMITTEE
above udorrn ition is correct. I agree to comply with all County ISSUANCE WEE
Ordinances and State laws relating to budding construction
and herebv authorize representatives of this County to enter TOTAL PER 00
t d upon the above-menuoned prop" for Inspection purposes
b /� SEE REVERSE FOR E7sPLa\ATORY La\GU AGE
cii-
r Slgnattrre of Pe 1•"lee% ate 1
I RORkLRS COAIPLVSATIO\ DELL IR\f10\ CE 875 MISCELLANEOUS APPLICATION
CE 8T5 11 861
1 hereby affirm that 1 have a eeComp n of Lonsem rL selt COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ,
unsure or a Lertftica[e of \loders Compensation lnsurame Ur I
a certified Lnp} thereof ISeL 3800 Lab C I
Polle% No Comnam FOR APPLICANT TO FILL IN SUILOINa !�
A
woon e3s eJ
Certdled cop, x hercmAUILDIN
b, [urshLa ODRES.e LOCALITY
I I
Certified Lop, is tiled with the Lounn buddme utspeLtion LOCALITY YEAR e3T
department Temple City cw osa ST
Date \nphLant NEAREST °m.RICT N/oC cw0OF Tvra S3SED
er
CIS
ST �DV CON3
1 CE RTIFIC ATE OF E\ETI%I PT10\ FROM IOR ILE RS LEGAL o awv,
COM PE\'S AF1 ON I\SLR\\LL oESCISIR, ov LOT Yo 'ULOCK 'M�^ 'c wCLSI STATE MAJOR SECOND LOCAL
NO OF 51.005to
(This section need not be Lompleted If the work imol,Ld '-R Ac- NOW ON LOT use PONE 3Pa cIwL covmnoNa
by the permit Is for one hundred dollar, I 100) or leas 1' use or
I SIZE °F -°T IE`113T1Y6 aLOi
1 Lertds that in hL pv 0nnans ,, Ise ,ail o shlcti his
permit is issu,d 1 ,hall lot emplo, in, °c von nam mannLT oxNeR
so as to became ,ublLLt 0 the \l orke•c C)maencltwv 'aw s x
OCCUPANC GROUP —
MAIL
A00Rfi98
f Dale \p\T It -_
nr
NOTICE TO APPLIC\\T It v e• m,km_ 'us C.^Tate �If gi clr � • YOL OCCUPCN-,OAC
E%emption Lou ,hotdd be:ome ,umec o hL \l o.ge , _
Compensation orm isions of III. I ihcr . )& IOU must tn•Tlt AP°L'CA 7IC„ =7F 9`(I- -ie-C",PE
1 "uh Lom Qi, ,ufh .u,li nro,h.nn, o, ht, •,rmit had be -RAILER ISE ❑ seowcY NeP3c- oY No Soee K iwvl
deemed•L,oneta —
LILNSEDCONIR\CTORS DECLARATIO\ °CJeANC 1NSP°`-104 Panic Dev'ces
L
I lre•eb, affirm hat I am licensed unde•nrc,monsor Ciav%- SAFETY PERMIT (LIST ITEMS eELO,vI
' 9 ILornmenLIM „till SeLtlon -000) of Dnision ., of ,he BIJSr NO OF EMTs
ness and P-ntesuon,Cade and m, license Is In ud orre and
eifeL PARK'"G RED o l.� rRo+lo Eo
SrCCE9
e LiCLnse \umb,r L c CIa„
LIMITED TIME USE
Contra,for
I am e%empt ,rom the li,,ma z reouve nems u I ar, i
m 1 licensed archrtLct Or a e_nstered pmfesstonal enemeLr -'zE or No oP I"sP TOR 3
'=J aLtlne n nl profLCLwnal art. t _, ,U1 �11c1 Bit, EIISTIIG el-C. 3�OP,SJ SI TURF
a mes,.nd P•otesfiLCs Cld.1
FINAL APoROV AL
u Lic or Rem \o
DI77 Pa ese YT use or eu uOlrvc
I _
11011L O\\Nl R BULDER DECLAR \(10\ NO or EXISTING vUIL°Inas !C f9f.PJ[T kF-E" / 'q«9
0 LOT AND Usc o // 1
I hereby at`um that I rm L\empt from ,he GmtnL2447 Ah 10 12,tor s '))J/�///III
1 License Lau for the follo„mg reason IS„tion -'I_1 _ Bua
ness and P-ofesslons Code) No FARMING
1 as o„ner of the proper, ,Sill do the cork and flit 9 P CC PROVIDED
struc,ure Is not intended or offered tar Srle ISeLtion
1 7044 Bu,uu,sand Prot Lttlons(ndL)
CONSTRLCTIO\ LLNDI\G AGI\Cl X PROPOSED USE or 9UILDIND
I herebs affirm that there IS a Lonstmctlon lending agents
I for thL pertorman” of ihL work for „0111.11 dus permit is
issued ISeL 3097 Cn C 7
Lend,r s Name
PROPOSED MAX OCC
Lender s Address ryL
I PERMIT FEE 25.00
1 cera(} that 1 have read this application and state that the
above Information is LorreLt I agree to Lompl} "fill all County ISSUANCE FEE
ordmam.es and State hotq relating to budding construLtion
and herebv authorise representatnes of this County to enter TOTAL FEE 25.00
4 upon the abo,e mentioned proper[) r ins elation purpo.es
SEL REVERSE FOR EXPLANATORY LAVGU\GC
/ ` 11
Signature of Pe ittee Dat