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Home My Public Portal About5723 SULTANA AVE_Miscellaneous__ WORKEdl RS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION f hereby affirm tkatI have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION nsure, or,Ra c8rtificaticate of Workers'Compensation Insurance,e,or I certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING ADDRESS LOCALITY ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST L tV DISTRICT NO. GROUP TYPE PR CESSED BY CROSS ST. ' ! CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. a 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 C%qn M,CtnC3Ve r U so as to become subject to the Workers' Compensation Laws. MAIL O OCCUPANCY GROUP o ADDRESS 2�;:] Date Applicant TEL �1 a NOTICE TO APPLICANT: If, after making this Certificate of CITY�, No. $��'y��'� OCCUPANT LOAD �, Exemption, you should become subject to the Workers' A PLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- with comply with such provisions OI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ ❑ ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. , Cj (1\CLfJ JU PARKING RE SPACES O'D D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE 0 1 am exempt from the licensing requirements as I am a FROM: TOI licensed architect or a registered professional eflgineer SIZE OF ^ NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. sN STORIES SIGNATURE iness and Professions Code). _ PRESENT USE OF BUILDING FINAL APPROVAL 7 f. Lic.or Reg.No. Date 9 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGSr ON LOT AN USE Lf FEE 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. PARKINGCGi I, as owner of the property, will do the work and the SPACES PROVIDED ^ _ - structure is not intended or offered for sale (Section i Gt1,.f f i a c•}� 7044,Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY X I I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is t issued(Sec.3097,Civ.Q. Lender's Name r PROPOSED MAX. OCC, Lender's Address a PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS-COMPENSATION DECLARATION 87� 11 841 4 CE MISCELLANEOUS APPLICATION ��E 87 .• I hereby affirm that I have a certificate of consent to sett COUNTY OF LOS .ANGELES BUILDING .AND SAFETY DIVISION y ' insure. or a certificate of Workers' s'CoCumpeq'<i[ion In�Jrince.or- a certified copy thereof[Sec.3801).Lab.C.1. 12 " Policy No. -Contaanyt FOR APPLICANT TO FILL IN BUILDIG 1 ACORESNS Certified copy is hereby furnished. ,Bu1LDING A11 . !�p / nQ LOCALITY !� g� i 1Certified :opy is filed with tate county building inspection LOCALITY NEAREST department. Temple City CROSS ST, Date Applicant NEAREST (/ �^ DISTRICT NQ- GRO P TYPE CESSED BY I CROSS ST. /�� / L(, Q -� y CONST. 1 CER rIFICATE OF EXEMPTION FROM�"ORKERS DESLEGAL CRIPTION LOT VO. I BLCCK I MAP O NIaHw Ar C l)\IPE\S:\TION IN R.\�C` loo. (CIRCLE) STATE MAJOR SECOND LOCAL N . OF SLOGS. (This section heel} not lie enmoleted if the work involved '-RACT NOOIN ON LOT USE ':ONE SPECIAL CONDITIONS by the permit is for one hundred dollars 61001 or less.) UF i ! I SILL OF LOT I EXSEISTOING BLO G :h . I certify that in e verformance of -h • o.e fa:•,•hiCh 'his --� - permit is issued. I ,}tall net employ any 7e-.ion :n any manner DINNER pr so as to become ctibiect :o the Workers' i;nwensation 111S. ,AIL "/e /' OCCUPANCI' GROUP I' ADDRESS a/ /wI � - I Date Xpplicant d -_ NOTICE TO APPLR ANT: It, tf-c- -nakir.- :!lis I ,rtifiCa((` ,t M CIT on-Ate t&k ,..,Ito -q?F 337 OCCUPAN`LDDC Exemption. you :hotild become .ubject :o -lie \11,rltea' Compens[non provisions if;he Labor .'Ades you mus[ tort It- I APDL!CA71C1 C?R '-:X ynRCWAPE with coni-fly will such arovi%imi,; , hi% ^crams ;hall he , deemed re—ked. ( -RAILER USE GEOLOGY :NSPTICY — No $U@C. iC:iC"/l, I LICENSED CONT it.\("TORS DE LAR.\TION 1 JCC 1PANCY INSPECTION$ r�IIIC Ce`rl�es ❑ I hereby afire :flat 11m licenseditnd2::Jro�•isnoils.�:('llapter SAFETY PERMIT '-' (LIST ITEMS 9ELON) v ! 9 icominen Cing with Section 7000) o DLision ,It :lie liusi- "' NO. OF EXITS Hess and I'-,,I'caulm Code. and m:• ticcntie !< in alai} force and effect. PARKING SPACES REO'D -R C•J ID ED License \uniber_ _—. L•,c. Cla>s LL �( LIMITED TIME USE H Contractor ..-- .-'-'---_. .._ IlaiC -- _'_.--_'-.---_ _ DATE DA-1: W ❑ 1/17 "j •sr M; .D• H lam exempt from the licensing reyuuc:nentc as 1 1111 .i Sol 1 licensed architect ,it a :etnsiered prnfeSUonal engineer SIZE OF Vo. Oma' INSPE OR's 2 actin- in my prrfr'„iOnal •;tr.izii•• Se,1-in -1':I. 1111.- 'EXISTINi BLDG, yes i79RIS3 r SIG A URE a ineYiltl.11':IIfe1511:t1�l.,Ilel. .J/ �� - -------------�---•-- V -RESENT USE OF BUILDING FINAL APPROVAL Lie.or Ree. \o. .-- _--- Da-e_--- S 1 Y IMIE O\\'\FR-BUILDER DECL.\R\Il()N { NO. OF EXISTING BUILDINGS ON LOT ANO USE I hereby affirm that l am exempt from the Contractor”. I License Law for the following reason (Section -1)31.:. Busi- ness and P:ofessionsCode): ;NO. PARKING 'SPACES PROVIDED 1, as ocaner of the property, will do the work and the j 19structure is not intended or offered for ;11e 1Section I I 7043.Rutiine,e anal Professions Code1. p I A I PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCIi ► _ 1 hereby affirm that there is a construction lending_ ;agency k �;� Sa e fl s l for the performance of the `.:•ark for which this permit is issued(Sec. 3097•Civ.C'.1. t o Lender's N:ung.____--.— —__-- ` (o 11 PROPOSED MAX. OCC. I Lender's.address w ( I certify that I have read this applit-ition and state that the PERMIT FEE 25,00 f above information is correct. I aeree to comply with all County ISSUANCE FEE I-' rill ordinance and State laws relating to building construction, rfl and Isere�ailthorize representatives of this County to enter I TOTAL FEE 25.00 -e � I I upon tl aboee- tion• propgrty for inspection perp ses. .� SEE REVERSE FOR EXPLANATORY LANGUAGE Ft 1 Si urs of Permittee 1 WN UU5 APPLICATION WOKKLI(b L-OMI'LNSAI-ION DE( I-ARAI I Mlbkt�LLANE_� I WIN 1. 1 TY 01 :TY DIVISION ent Its sell COLIN - I.OS ANGI:LFS 131.111I.DING AND SAIT -,I hereby affirm that I have a cel-lifiCuIC Of COHN insure,or a certificate of Workers"Cotopensation ln%urance.or • I certified copy thereof (Sec. 3800. Lab.C.) FOR APPLICANT TO FILL IN BUILDING E Policy, No. Company BUILDING ADORE ADDRESS HCertified cop), is hereby furnished. �.SNnnok. AVf LOCALITY Certified copy is riled with tile county building in'-pection CITY ZIP NEAREST C S, ?,Pv : .ST. L—r Cr CROSSST. department. tm-ple _____ _ TYPE PROCESSED BY Date Applicant SIZE 6F LOT' 0.OF BLDGS.NOW ON I OTi GROUP CONST. 13 CER'I'll-WAIT 01: EXLMIITION FROM NVL ORKI.RS' :rRiAeT71. COMPENSATION INSURANCE !CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work -,n%ol%cd ASS ESSOR MAP BOOK ILOCK LOT NO. MAP HIGHWAY PAGE PARCEL USEZONE J!PECIALCONDITIONS by (he permit is for one hundred dollars (SIOO) or lc%%.) OWNER TEL NO. I certil*y that it) the performance of the %%ork lot %khich [hist.4- permit is issued, I shall not enlrilu) anylie'-still In dIIV 1111111liel, r. AA_ _M ADDRESS OCCUPANCY GROUP so as to become subject to the Workers' Compensation Liras. Jak tin_4_S Dr. Date Applicant CITY T4*04I CA ZIP OCCUPANT LOAD NOTICE TO APPLICANT: 11'. atter making this CCrIiI*iCZttC of Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor(*title,you must forthwith comply with such pro%isions, or llli% permit shall be devilled TRAILER USE LJ GEOLOGY INSPECTION No Spec.Knowl. ❑ revoked. ❑ OCCUPANCY iNSPECTIONN Panic Devices LICENSED CONTRACIMS DI.CLAR C110N I hereby affirm that I am licensed tinder provisions of(hapter SAFETY PERMIT O LIST ITEMS BELOW NO.OF EXITS 9(commencing with Section 7000)of Di%ision 3 of the Business and Professions Code.and my license ii in full three and effcet. PARKING SPACES REQ' E= O PROVIDED License Number I le.Class 61 A- d4d—ld_d� LIMITED TIME USE Contractor Dale DATE DATE am exempt from tile licensing requirements as I aill it FROM: TO: cd professional INSPECTOR'S licensed architect ora register engineer NeI or SIGNATURE EX !AORILt. s%ional capacil) I.ection 70i I 1ltI%itIC-,% sizr OF ICLillg in 1111 prole Ib I IN,,Ut I IG. and Professions ('ode). Lie. or Reg. No. Date PRESENT USE OF BUILDING FINAL APPROVAL IIONIL OWNFR-111111 DI R IN ( I AR XIION flit'. 4 it'I A V�I IN(OUR DINGS 0111 UI AND UbL I hereby affirm that 1 ain e\enipt from the Conintelor's I icense Law for the following reason (Section 7031.5. Business and Professions Code): NO PARKING El 1. as owner of the pro)iert\- will do tile and 111V IPASES PR IDED structure is not intended or offered 110i sale(Section 71614- PROPOSED USE OF BUILDING lVh Business and Professions Code). CONSTRUCTION LENDING '\GI NC Y I hereby affirm that there is-.I construCtion lelldllie apinlo I'I'r tile perl'ormance of the work for MIMI 1111% IICrIIIIL Is Issuld PROPOSED MAX.OCC. (Sec. 3097.Civ.C.). Lender's Name APPLICANT ffMlir) TEL NO, Q Lender's Address ADDRCSS arJ _7 1 certify that I have read this application and state that the Ave, Te,.Dk above in forma Lion is correct. I agree tocoiliply withall COLinty PERMIT FEE ordinances and State laws relating to building construcIion,and hereby authorize representatives or this County to enter upon ISSUANCE FEE the above-mentioned propert3 for inspection purpo%e%. yl TOTAL FEE X Sr-I_ REVERSE FOR EXPLANATORY LANGUAGE Signature of Perifi-hice Date