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Home My Public Portal About5616 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M4" % CE 876 (780) MISCELLANEOUS APPLICATION I hereby Sierra that Irhare S,eemficate 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 3900 Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING ADD❑ ESS Certified copy Is hereby furnished au uoina L Louury ❑ woOn¢SS V Certified copy Is fled with the county budding inspection A, NEAREST department LocwLirr ROSS 89 S8T Dale Applicant awn EST DISTRIc o u TYPE PR SS6D By CROSS 8T CONST CERTIFICATE OI EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRiPnoN Lor No BLOCK A iGNwwv } xOr IC IROLR) STATE MAJOR SECOND LOCAL a (This section need not be completed d the work involved No OP aLoaa use zone EP ECIAL CONDITIONS O rR wcT rvox on LOT U by the permit is for one hundred do0us ($100) or less) O USE,I 8126 OR LT E%iSTITINO BLDG W I certify that in the performance of the work for which this O permit a issued, I shall not employ any person in any manner wrveR .1 F so as to become subject to the Workers Compensation Laws AIL /V OCCUPANCY GROUP W ADDRESS C Il Date Applicant Z NOTICE TO APPLICANT It after making this Certificate of CITY 11 NoL OCCUPANT LOAD Exemption you should become subject to the Workers APPLICATION FOR I EXIT HARDWARE Compensation provisions of the Labor Code, you must forth with comply with such provisions or this permit shall be Tn AILEn USE GEOLOGY INSPECTION deemed revoked ❑ ❑ No Spec Knowl ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPEcnon Panic Devices ❑ I hereby affirm that I am licensed ander provisions of Chapter eARETv PERMIT q (LIST ITEMS BELO.) No OF EXITS 9 fcommenemg with Section 7000) of Division 3 of the Bus, ntsect s and Professions Code and my license ,s ,n full force and PARKING e/f ,/ RQO D ense Number LPROVIO6D A2sz9d..� /KCtI'. L ¢ Class SPACES LIMITED TIME USE Contractor/D z_pf� Date 2— 3 DATDwT¢ ❑ TO 1 am exempt from the hLensmg requirements as I am a Ilcensed architect Or a registered professional eng,reer SIZE OF rvo oR INSPECTOR acting In my professional capacity (Section 7051 Bus- E%iSTING BLDG STORIe9 nanwru RE ,nees and Professions Code) ESENT USM,OK BUILDING FINAL APPROVAL Lic or Reg No - Date- HOME o DateHOME OWNER BUILDER DECLARATION NO of ¢%uTING BUILDINGS ON LOT AND u89 I I hereby affirm that 1 am exempt from the Contractor's ` License Law for the following reason (Section 7031 5 Btoo 0 7 5 O 0 N ness and Professions Code) rvo PARKING NO PROVIDED ❑ 1 as owner of the property will do the work and the #t.• • . w 88 structure Is not Intended or offered for sale (Section I 7044 Business and Professions Code) it RonoseD USE OF BUILDING R w R w w CONSTRUCTION LENDING AGENCYOc,F, s 1 2 p 9—8 3 1 hereby affirm that there Is a construction lending agency 1 for the performance of the work for which this permit ,s 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 budding construction TOTAL FEE and hereby authonre representatives of this County to enter upon [he bove ntio d oper[ for inspe5pion purp ses SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of PermlWe Date WORKERS'COMPENSATIONDECLARATION CE 875 12-801 - MISCELLANEOUS APPLICATION �J CE 875 NJ 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 BUILDS.' /�.. G,,. ❑ ADDRESS c.at[:!t. Certified copy is hereby furnished. BUILDING ADDRESS •I - LOCALITY �.�� -c _ / ❑ Certified copy is filed wifh:the county building inspection department. , new REST ' LOCALITY ,+ Y CROss .T. _ Date Applicant NEAREST 1 CROSS ST. - ! 4 DISTR)GTwO.: 'ROUP TYPE _ ., PR E89E0 BY 1 L "A f / CONST, '� IL CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL _"'r v' J ��" � Oa COMPENSATION INSURANCE DEsaRIPT..N LOT No. BLOCK MAP I..wwv (uwCLe) STATE MAJORaECOND LOCAL U (This section need not be completed if the work involved NO. OF LOGS. y3E ZONE SPECIAL CONDITIONS W P TRACT NOW ON LOT J by the permit is for one hundred dollars ($100) or less.) - ueE of � % Il certify that in the SIZE OF LOT EXISTING BLDG. performance of the work for which this , 1 _ ermit is issued, I shall not employ any person in any manner '-' OWNER , i � ' �- 's"")N > as to become subje'ct to the Workers' Compensation Laws. MAIL •) OCCUPANCY GROUP ^..• < ADDRESS _ i J / " �!,�• %� ate Applicant Q NOTICE TO APPLICANT: If, after making this Certificate of CITY p" .TEL OCCUPANT LOAD a Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: W Compensation provisions of the Labor Code, you must forth- LU with Comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION N ❑ deemed revoked. o Spec. Knowl. LICENSED CONTRACTORS DECLARATIO OCCUPANCY INSPECTIONS Panic Devices ElI hereby affirm that 1 am licensed under provisions- Chapter SAPeTY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of he Busi- ness and Professions Code, and my license is in full Sea and PARKING. effect. SPACES REO'O O PROVIDED D License Number Lie.Class LIMITED TIME USE Contractor Date AT. ..TP ❑ RROM: T. I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer size qF ND. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). PriESENT usE BUILDINe_.. FINAL APPROVAL Lie.or Reg-No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTINGUSE BUILDINGS I hereby affirm that I am exempt from the Contractor's ON LOT ANO License Law for the following reason (Section 7031.5, Busi- 77 ' ^,C ) ness and Professions Code): NO.PARKING SPACES PROVIDED Ell, as owner of the property, will do the work and the a structure is not intended or offered for sale (Section 7044,Business and Professions Code). a a Rovos9b use of BulLolnc CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency " ' a /,.a T -4a „K-1"-•' for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROP09E0 MAX. Dec. 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 Stale laws relating to building construction, TOTAL FEE - and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVFR9E FOR EXPLANATORY LANGUAGE Signature of Permittee Date 74 NORKERS'COMPENSATIONDECLARATION CE 875 111 94) MISCELLANEOUS APPLICATION CE 87a 1 hereby affirm cert that 1 Workers a certltmpen 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 w DDRESS., ��` Q Certified copy is hereby furnished EUILDINO wD DR¢SS LO Cw LIrr 0 Certified copy is filed with the county building inspection -ADDRLOCALIESS NEAREST department CM XS ST Date Applicant NEAREST DISTRICT No ewouP TYre c¢SS¢D Br CROSS DT CONw CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 0 "a COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCKION.. No• (CINCLS) STATE MAJOR SECOND LOCAL (Thu section need not be completed if the work involved rwACT nNO or LDca ow onELor USE :owe SPECIAL CONDITIONS by the permit Is for one hundred dollars ($100) or less.) usE or SIZE OF LOT EXISTING BLDG I certify that in the performance of the work for which this r 1 o permit Is issued, I shall not employ any person in any manner OWNER 0` Bt-Mi Cindy S. Sun Od `o so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP z 0 wDDRE.¢ 5616 N. Rosemead Blvd Date Applicant W NOTICE TO APPLICANT If, after making this Certificate of CITY Temple Cit ;c>5213 2660222 OCCUPANT LOAD o- 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 ❑ GEo LoaY INSPECTION ❑ No Spec Knowl deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that 1 am licensed under provisions of Chapter awn ETv P¢RMIr ❑ (LIST ITEMS BELOW)9 (commencing with Section 7000) of Division 3 of the Bust, Q 4.5i f1tSS NO Or EXITS ness and Professions Code,and my license Is in full force and tl Mtt 0 PARKING effect BSPACES SEC,D PRGv"" License Number Lic Cl rimTTyn ASIAN CO. LIMITED TIME USE Contractor Dale GATS GATS ❑ I am exempt from the licensing requirements as I am a "DM licensed architect or a registered professional engineer SIZE orNo or INSPECTOR s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE mess and Professions Code) PRESENT USE OF BUILDING O F FINAL APPROVAL Lic or Reg No Date 5616 N. Rosemead Blvd NO F HONE OWNER-BUILDER DECLARATION NO Or EXISTING BUILDINGS 0 oN LOT AND US¢ / 1 hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5, Bust- 4 /r- M_ —11001 6/ 997 ness and Professions Code) NO PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED 01680 1 AM 7:?7 structure Is not intended or offered for sale (Section 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING GE 1 hereby affirm that there Is a construction lending agency 5616 N. Rosemead Blvd for the performance of the work for which this permit Is Issued(Sec 3097,Cry C) Lender's Name PROPOSED MAX OCC Lender's Address PERMIT FEB '215. 00 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 orduances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL PEE 5 upon the e-mentioned p ty for Inspection purposes / I ` SEE REVERSE FOR EXPLANATORY LANGUAGE er Signature of Pevnittee Date WORKERS COMPENSATION DECLARATION 18A14I44 10 DJ 12/90 MISCELLANEOUS APPLICATION I hereby amrm that 1 have a cendicate of tons m to sen COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insum or a cenlfaate of Workers Compensation In+uranLL or a certified copy thereof(Sec 3900 lab.C) d Policy N0. Company_____ _ _ _ _ FOR APPLICANT TO FILL IN BUILnrNc 8BUILDING ADDRESS _ ADDRESS Certified copy Is hereby furnished (� gl� LOCALITY Certified copy Is t ted with the county buddmL impLLtion Chir ZIP I 17t J department "EARN cRoas ar Date _ Applicant_ _ SIZE OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GRDUP TYK PROCESB[D BY coNST CERTIFICATE OF EXEMPTION FROM WORE LRS TRACT BLOCKLOT NO ,J COMPENSATION INSURANCE •• MOKr.. Mf yes . "ATE MAJOR SECOND LOCAL by t SectionGerm (laid o be completed d If the 100ork ins olved ASSESSOR MAP BOOK PAGE PARCEL USE ZON[ SPECIAL CONDITIOIIS I by the permit n for ow hundred dollan (,IIN)' or kss.l , J I certify that in the performance of tin wort for +hlLh this OWNER TEL No r I permit Is Issued I shall not emplu) an) person In In) mannLr f so az to become subject to the WorkersCompensation L IPA+ ADOREss OCCUPANCY GROUP Date Applicant _ _ cri-Y ZIP NOTICE TO APPLICANT If after making this ertdaate of Eumption you should become subject to ihL Workers APPLICATION FOR OCCUPANT LOAD Compensation provisions of the Labor Code you must forthwith EXIT HARDWARE comply with such prosisions or this permit shall bL deemed TRAILER Use❑ GEOLOGY INSPECTION❑ NO Spec Knowl ❑ revoked pI Pe ! LICENSED CONTRACTORS DECLARATION OCCU NC♦INSPCCTIONIC Panic Devices ❑ 1 hcmb% affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT❑ ILISTmemsaELOWI a J 9(commencing with Section 7000)of Di%ision I of tl. Business NO OF"ITS and Professions Code and my license is in lull Ione and efri cl IJ" 6 of r 31MF!'+`s PARKING LicenseNumber ___ ___ ____ Llc Uax x + 6 MCES O° PROVIDED Contractor _ Dne UMITED TIME USE ElI am exempt from the licensing requirements DATEments Is I am a mom TO s licensed arehnect or a registered prolimion.0 LnEmeer acting in m) Profusiunal Lapauls (tiLLuon 7051 BLIMIk+s SIEEOr No of INSPECTOR 9 —) and Prolt"jom Codo EXISTINCSLOG sroRlEs a RE LIC or Reg No Date_ _ _ PRESENT USE Or BUILDWG FINAL APPROVAL — i HOME OWNER-BUILDER DF( I ARAI ION NO OF EwsTINC 9INLDINGS ON LOT AND USE 1 hereby alfmn that I am e+empt 1nulh ilk Conirduul . LmoiM I/ Law for the following reason (Section 70315 BnsuiLs+ and Professions Code) NO PARKING ❑ I a3 mner til the ft 9PAees PROVIDED p yKrry x111 Jo UtL xut uW ilk structure is not Intended or oll,rLd Sul SliL (40ion 71144 PROPOSED USE OF BUILDING Business and Professions Code) I CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending Eon) for the performance of the work for which this p mut Is IssuLd (Sec 3097 Civ C) PROPOSEDMAK OCO VI Lenders Name --------- APPnANrrawr TEL No D I i Lender s Address AOR;C q>1 PI e Is.) 1 certify that 1 have read this application and state that the L1! f q 1 6 above information Is carrecL I agree to comply with all County PERMIT PEE I ordinances and State lam relating to building CM[rULllon and hereby authonn representatives of this County to enter upon IBBUANCE Fee the above-mentioned property for inspection purposes Vt I V �I TOTAL PEE /l ZLMd'IL C. SEE REVERSE FOR EXPLANATORY LANGUAGE RSignetur Pemllnee Care I I WORLLE" I.UMYtNJA11vN LM1_LAKAIIUN 20-00e3DPsv12/90 MIDL.C,LLHIVCVIJ' At-l—L-11.A1 IV111 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING AND SAFETY DIVISION ( Kim m cr a certificate of Workers'Compemation Insurance, or l � � a certified copy thereof(Ste 3800, Lab.C) - '-, - - j i Policy Na Company FOR APPLICANT TO FILL INLDmo BCerufted copy is hereby furnished 1i Vu, z--Ar> E3L Certified copy is filed with the county building inspection CITY `� ZIP NEAREST r 1 I department. m C-V` Asa� .. Date Applicant SIZE OF L .� NO OF BLDGS NOW ON LOT DBRRK:T NO egouP TYn[ iyeolxsaED ev CONST a CERTIFICATE OF EXEMPTION FROM WORKERS ( I COMPENSATION INSURANCE TRACT BLOCK Lar NO STATE MAJOR SECOND LOLL (This section need not be completed If the work involved ASSESSOR MAP BOOK PAGE PARCELCA by the permit m for one hundred dollars ($100) or less) uee zoNE ivEUAL coNixrKMia f � I certify that in the performance of the work for which ilii rff e TEL No I permit is issued I shall not employ any person In any manner I so as to become subject to the Workers Compensation Laws. ADDRESS OCCUPANCY GROUP rar7 ( I Dale Applicant STY ZIp ? NOTICE TO APPLICANT If after making this Certificate OCCUPANT LOAD of Exemption you should become subject to the Workers APPLICATION FOR Compensation provisions of the Labor Code,you most forthwith EXIT HARDWARE comply with such provisions or this permit shall be deemed rgAILeR USE❑ GEOLOGY INSPECTION revoked No Spec Knowl ❑ OccUMNCY INSPECTION C$ Panic Devices ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter aAFeTY PEamn,0 (Liar rrems eELowt 'Ll f I 9(commencing with Section 7000)of Division 3 of the Business o 88 No OF e "Ir and Professions Code and my license is in full force and effete i� MRKING p!O D � PROVIDED I i License Number Lic Class r �L) L MRKIN i_ ( I I Contractor Date LIMITED TIME USE ❑ I am exempt from the licensing requirements as I am a DAT! DATE licensed architect or a registered professional engineer mom TO acting in my professional capacity(Section 7051,Business mss Or No or INSPi:croR s (- I and Professions Code) aXISnNG(SLOG smoniea SIGNATURE Lic or Reg No Date PRESENT USE Or BUILDING FINAL APPROVAL a L HOME OWNER-BUILDER DECLARATION Ne, or"IATING WIWJNGS ON LOT AND USE I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 70315 Business and 1 Professions Code) NO MRKING SrwcES i ❑ I as owner of the property will do the work and the PROVIDED structure is not intended or offered for sale(Section 7044 1 PROPOSIM USE OF BUILDING I Business and Professions Code) i CONSTRUCTION LENDING AGENCY I 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ( i (SEC 3097,Civ C) PROPOSED MAX oCG leaders Name Nr( I I 54-qv* Lender a Address MWT IA ( 1 certify that I have read this application and state that theCrEY above information IS correct I agree to comply with all County �Mrr IEE ordinances and State laws relating to building construction and hereby authorize representatives of this County to enter upon MSUANCE ME the above-mentioned property for inspection purposes. TOTAL TEL $ e &A Lf SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Dale COUNTY OF UOS ANGELES TEMPLE CITY # 0508 MISCELLANEOUS PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS MP 0508 0912160001 BUILDING AND SAFETY / LAND DEVEIAPWPM' TEMPLE CITY CA 91780 PHONE (626) 285-0488 EAT LEGAL ID NO OF CONST NEW BUILDING ADDRESS ON FILE I SQ FT STORIES TYPE OCCUP GROUPI 5616 1/2 ROSEMEAD BL 19T8UCTURE 1 V-B C I TEMP CA 917801849 ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET IAS TUNAS 5387-028-016 IE(IST BLDG USE (EXIST OCC GRP USE TANS i THOMAS PAGE 596 GAID H4 SAGACITY TEMPLE CITY, Cl TENANT ISSUED ON PROCESSED BY EXPIRES ON I BLOGS NOW ON IAT VALUATION 12/16/09 SR 06/14/10 OWNER TEL NO 0 FINAL DA'TL FI)ML BY CODE SUN, CINDY (626) 709-7492-AL (LIST ITEMS If��-�f/� L..� 119766 PINE CREST IWALNUT CA 91789 JOESCRIPTIO1. OF WORK REMOVE UNPERMITTED SUBDIVIDED WAIL FROM INTERIOR OF C0MIERCI OCCUP LOAD EXIST IAL BUILDING APPLICANT TEL NO IOCCUP IAAD NEW ISAME AS OWNER - (PARKING SPACES REQUIRED SPECIAL CONDITIONS PARKING SPACES PROVIDED EXIT HARDWARE CONTRACTOR TEL NO 1 LIMITED TIME USE SAME AS OWNER INBR OF EXITS 1 LIC NO I I FEES PAID APPROVALS DATE INSPECTOR SIGNATURE _IFEE DESCRIPTION QUANTITY DOM AMOUNT ARCHITECT OR ENGINEER TEL NO TRAILER USE I I OA PERMIT ISSUANCE 27 75 LIC NO 01 R/M OCC/USE INSPECT 145 95 (SAFETY PERMIT TOTAL FEES 173 70 ITP STRUCT APPROVED IMAP NO SEWER MAP BOOK PAGE FIRE ZONE CMP I _ TEMP STRUCP REMOVED INO OF FAMILIES DWELLING UNITS APT/COND STAT CLASS I I I NO SCHOOL _ I I I SCHOOL WITHIN HAZARDOUS I (AIR QUALITY 1000 FEET MATERIALS 6NO NO NO REQUIRED TOTAL SETBACK FROM EXIST SET BACK YARD HWY PROP LINE WIDTH - IFRONT PL- I SIDE PL- 1 1 I I I I I ( I I I I I I I I I I I I I (REPORT ID DPR267 ROUTE TO BS0508 I I I I I I I I