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Home My Public Portal About5725 SULTANA AVE_Miscellaneous__ ,.WQRKERS'COMPENSATION DECLARATION 76 44 (2-801 or I"' I SC E L LA N EO U S APPLICATION h Are affirm that I have certificate of consent self insure, or a certificate of Workers' rs'Compensation Insurance, e,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANTTO FILL IN BUILDING ❑ ADDRESS S - Certified copy is hereby furnished. AgUILDING ;� n LOCALITY A DRESS 1✓ � Certified copy is filed with the county building inspection I e C I NEAREST 04, department. LOCALITY CROSS ST. Date Applicant EAREST DISTRICT NO. G UP TYPE PROCE D BY CROSS ST. L J /JY +7 CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ( ALJ (/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP �jj HIGHWwv STATE MAJOR SECOND CAL >_NO. OF BLDGS. NO. �(% (CIRCLE( a (This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars (S100) or less.) USE of U SIZE OF LOT EXISTING BLDG. ' It 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 Joh K Co,i 0 ve O1-- so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP W 81 AD RESS 6O O. 421 a llate Applicant U) TEL. NOTICE TO APPLICANT: If, after making this Certificate of CITY JP C, OCCUPANT LOAD Exemption, you should become subject to the WorkersApp CATION 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 C] No Spec. Knowl. ❑ deemed revoked. OCCUPANCY INSPECTION Panic Devices ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) a No. of EXITS 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect. PARKING SPACES REO'D PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as 1 am a FROM: TO: licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL RESENT USE OF BUILDING Lic.or Reg.No. Date ho h� HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE A 1 6 1L 2 ,I I hereby affirm that I am exempt from the Contractor's L H License Law for the following reason (Section 7031.5, Busi- # D o 0 0 8 8 ness and Professions Code): NO. PARKING SPACES PROVIDED E1, as owner of the property, will do the work and the o 0 0 0 0 0 0 In structure is not intended or offered for sale (Section 7044, Business and Professions Code). O0 3,06-85 RPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter the above-m boned operty for 'nape n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si i of Y /� Da �� :, 1VORYXRS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to c 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.Q. R BUILDING Policy No.—Company FOR APPLICANT TO FILL IN ADDRESS Certified copy is hereby furnished. BUILDING S Z,�— S V N LOCALITY ADORES !� V E . Certified copy is Filed with the county building inspection LOCALITY nn , p NEAREST P ❑ department. \ EMLt- GI 7-Y pl 1 u CR OSS ST. Date Applicant NEAREST /^� p _� ee p DISTRICT NO. GROUP TYPE ROCESSED BY CROSS ST. I_A-.s T`I tV �� •`� CONST. CERTIFICATE OF EXEMPTION FROM\VORKERS' LEGAL COMPENSATION INSURAN�E DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLCI STATE MOR SECOND LOCAL NO. OR BLDG9. // (This section need not be completed if,,the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS / by the permit is for one hundred dollars ($100) or less.) USE OF I certify that in the performance of tld work for which this SIZE OF LOT EXISTING BLDG. permit is issued,I shall not employ anV person in any manner owNER F ,1'7\-9 _ �OL1 E `� so as to become subject to the Workets' Compensation Laws. MAIL P OCCUPANCY GROUP o / ADDRESS 1 fl a I H Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of CITY �( & L& Lr NEL' � OCCUPANT LOAD y Exemption, you should becom6 subject to the Workers' APPLICA ION FOR EXIT HARDWARE: z Compensation provisions of the,`Labor Code,you must forth- with comply with such provisions oI this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Know!. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIO Panic Devices El I hereby affirm that I am lic6nsed 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 , � SS effect. PARKING SPACES R9Q'D PROVIDED / License Number Lic. Class ''"°�'� LIMITED TIME USE Contractor Date DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING � Lic.or Reg.No. Date ✓, HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS c ON LOT AND USE / I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING El1, as owner of the property, will do the work and the SPACES PROVIDED NCO FEE structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING I Iucc-i IJt)� 9/13196 I hereby affirm that there is a construction lending agency �ljCo�L �.Q �L,Q///G� _1_,.tin Ph `gy 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 I have read this application and state that the PERMIT FEE �- 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 abov mentioned pro eTt f inspection purp � SEE REVERSE FOR EXPLANATORY LANGUAGE I Signature of Permit a to ` WORKERS'COMPENSATION DECLARATION 1ofq 20-0063DPW12/90 ''II+��.-1:-1.,,j,.,AN1-;(,,,jU--j A -j- 1-111I .lal nim I hereby affirm that I have a certificate of consent to self COUNTY OF L04-ANGELES BUILDING AND SAFETY DIVISION a • � 46sttre,or a certificate of.Wtlr'kers'compensation Insurance,or a certified copy thereof(Ser;. 3800, Lab•C.) - :_• Pbhcy'Noa_comPapFOR APPLICANT TO FILL IN BUILDING . ' `' BUILDING ADDRESS �- _(, ADDRESS Certified copy,is hereby furnished l �,7(A�l T Gt �jj• trscAUTM I Certified copy is filed with the county building inspection CITY j"� + ZIP I department. ��e(� f .l I JG r NEAREST Date `=' = Applicant L/ / O r-Ross ST. AP SIZE OF LOT ;6 0 S NO.of BE, .NOW ON LOT DISTRICT NO. GROUP 60NE51. PROCESSED BY CERIIFICAIE*OF EXEMPTION FROM WORKERS' TRACT BLO K LOT NO, MAP HIGHWAY I ,COMPENSATION INSURANCE I NO. (CIRCLE) STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) ZADORE;S5 T L O. I certify that in the performance,of the work for which thisWane tpermit is issued;I shall not employ any person in any mannerso as to become subject to the Workers' Compensation Laws• /Z OCCUPANCY GROUP ui Date Applicant . IP z NOTICE TO APPLICANT: IT.' after making this Certificate a r f OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR Compensation provisions of the4.Abor Code,you must forthwith EXIT HARDWARE: comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ revoked. No Spec.Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION It Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) I 9(commencing with Section 7000)of Division 3 of the Business �� o UNO.OF EXITS and Professions Code,and m license is in full force and effect STIIeBS 'i❑ License Number Lic.Class 1 SPACES PARKING• REQ'D C� I t" PROVIDED I Contractor Date V1rwl �' Y LIMITED TIME USE ❑ I am exempt from the licensing requirements as I am a DATE DATE licensed architect or a registered professional engineer FROM: TO: I acting in my professional capacity(Section 7051,Business SIZE OF INO. INSPECTOR'S and Professions Cade). EXISTING SLAG. sroRtES` SIGNATURE, PRESENT USE OF BUILDING ` Lia or Reg Na - Date FINAL APPROVAL ' HOME OWNER-BUILDER DECLARATION � NO.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 703I.5. Business and s Professions Code)- ND.PARKING i ❑ L as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING Business and Professions Code), r i CONSTRUCTION LENDING AGENCY i j I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued t (Sec.3097,Civ.C.). PROPOSED MAX.OCC. j Lender's Name APPLI N ffRWTJ NO. dl t Lender's Address ADDRESSUjj� b j I certify that I have read this application and state that the °�`� 1 V 1 above information is correct. I agree to comply with all County PERMIT FEE I ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE �- the ab ve-mentioned property for inspection purposes. • i TOTAL FEEio 4 , e �r /y ... l/ a� SEE REVERSE FOR EXPLANATORY LANGUAGE~ r Signature of mittee Dam (01 I I WORKERS'COMPENSATION DEC'L.tRATION 8 CE75 �r•aa) MISCELLANEOUS APPLICATION r, ct:s�s I herelly affirm that I have a certificate of consent to self insure. or a certificate of Workers'Compensation Insurance.or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ! a certified copy thereof(Sec.38110.Lab.C.1. I " Policy No. _Company FOR APPLICANT TO FILL IN ADILDIN DRESS �p?� Certified copy is hereby furnished. BUILDING ADDRESS -S �p..h,�� LOCALITY I 0 Certified copy is filed with the count} building inspection LOCALITY NEAR EST department. Temple City ck\-19 0 CRoss ST. Date Applicant NEAREST DISTRICT Nf� G UP TYPE ESSED BY CROSS ST. D y' CONS I CERTIFICATE OF E\ENIPTION FR0%I 1'0RKL•Rb LEGAL O t ONIPENS.i TIO^ INS(R\NC 1E 1 ' DES CPIPTIO.4 LOT NO. BLOCK I NAP .1G11WAr STATE MAJOR SECOND LOCAL NO. OF BLOCS. `.O. ICIR CLE( (This section need not lie completed if the cork involved 1-RAC- NOW ON LOT USE TONE SPECIAL CONDITIONS by the permit is for one hundred dollars (S1001 or less.) t usE OF ( ! I SIZE OF LOT EXISTING SLOG. 1 certify that in rhe performance ,f -he•sari• :u:•Which :his permit is issued. 1 ,hall not em k+, any neaon :n any manner ' - P P •.'k DVVNER �Q 50 as *o l�eceme cuhiecr :o the ri'orke:c ;!n^ensatio^. l.al\C. NAILh OCCUPANC" GROUP ADDRESS 2j() M. 6181 IR #312_ Date :applicant -_ NOTICE TO APPLICANT- if, ai:er makine :his C ni ieare !,t .XI C1T••Kp ilm ark �D _ 8-33 (� OCCLIP4.1V-LOA-0 - Eeemptio•1. %-oil :hrnld become iubiec: -o -he \CnrBe-,' Compensation vrovisions -if :he Labor-'.,de. you mutit rnCh_ APD!'CA-1CN' C SG 1 with comniy a ill: .ugh -tovisioni lik ernin ;hLil !,e GEOLOGY -w OILER USE No Soec. Knc,vI. deemed:c+elated. - — LICENSED CONTRACTORS DECLARATION INSPECTION$$ Pan;c Dev Ices I hereby affirm ;hat I am licensed under orevisionso Chame- SAFETY PERMIT (LIST ITEMS BELOW1 ' 9 !commencine with Section "0001 of Division 2 Jt the Busi- NO. OF EXITS ness and P-nfes%ion Code. and m, licence is in :till force and effect. PARKING SPG CES REO•D 1 PROVIDED y Licenw 'uim lvr_ Lic. Cl.r<. LIMITED TIME USE H Contractor—__ 11:IIC_ _—._ DAre ogre W Z ❑ .^J M: gyp• I am exempt from ate :icensinc reauirernentc :is I am a g I licenced architeC: or a :e2istered prnfessional enLtneer ;IZE OF .4D� I eSCE E z actin_ in •n}• prrfe'xional arl�:r :: :,,: -n;l Hui- FXISTIV, BLDG. 3% iness and I'rnicsicn:t:, -- de1 V 'RESENT USE OF BUILDING FINAL APPROVAL ( 7 Lic.or Rec. \o. I HOME 0\\N1 R-BUILDER DECLARATION NO. OF EXISTING BUILDINGS � `A ON LOT AND USE �\ 1 hereby affirm that I .un exempt from the Contractor*,; l License La%% for the folio„in,_ reason (Section -II31.:. Blvi- ` ness and Professions Code): NO. PARKING n1 1. as owner of the property. will do the ,work and the SPACES PROVIDED structure is not intended or offered for :ale (Section \ l 7414•I;ruSilleis and PrtlfeSSitinS('tide). CONSTRUCTION LENDING AGENCY $ PROPOSED USE OF BUILDING I hereby affirm that there is a construction lendine agoenev I for the performance of the ,Fork for which this permit is issued(Sec. 30Q7.Civ.C.i. Lender's Name PROPOSED MAX. OCC. I Lender's.address �— PERMIT FEE 25.00 I certify that 1 have read this application and state that the above information is correct. I a^_ree to colnply with all C•orlllt`•.' ISSUANCE FEE ordinances and State laws relating to building construction. and hereby authorize representatives of this County to enter TOTAL FEE 25.00 1 upon the above-mentioned property for inspection purposes. (A)04 UN SEE REVERSE FOR EXPLANATORY LANG(1•►GE I $- Signature of Permittee Date