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HomeMy Public PortalAbout4509 TEMPLE CITY BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE6412801 MISCELLANEOUS APPLICATION I pereby 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 Lab C ) Policy No Compass) FOR APPLICANT TO FILL IN eulLol Na ''J'' ❑ BORE / Qr Certified copy Is hereby furnished BUILoino �y p� ❑ - ADDRESS 7r �/ /p Q1PL� i7Y ��j 03 LOCALITY Certified copy Is filed with the county building Impaction NEAREST department Loc ALITY T TY A cROS¢ is .56 Date Applicant NEwR¢ar DISTRICT No a our Trve Pwoc S co Br cwoan ST /�P► sr^ 2Uj 51 1go •� corvaT / CLRTIEICATE OF EXEMPTION FROM WORKERS LEGAL v DESCRIPTION Lor no BLOCK w .....AYY COMPENSATION INSURANCE ..oe 1o.cu1 STATE MAJOR ace O LocwL its. N.0. OF IsLDGS � (This section need not be completed if the work involved TRACT rvoW ON LOT USE ZONE eP ccIAL CO.------ U by the permit is for one hundred dollars ($I00) or less) USE OF �9 SIZE OF LOT EXISTING BLDG' (/ cc 1 certify that In the performance of the work for which this _ 0 permit a Issued I shall not employ any person In any manner Owne P�� �k Qh lU' so as to become subject to the Workers Compensation Laws MAIL � s OCCUPANCY GFjOUP�. _ W ADDRESS /�O, ,OVy 69IJ ' - • ` \ . a Date Applicant J N NOTICE TO APPLICANT If after making this Certificate of clrr e/p/�,� Crtr TE y'/Z .Z« O s OCCUPANT LOAD Exemption you should become subject to the Workers Compensation proslsions of the Labor Code you must forth APPLICATION FOR 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 oecuvwracv INwccnoN Panic Devices ❑ I hereby affirm that I um IiLensed under provisions of Chapter SAFETY PERMIT (LIST ITCMa BELOW) No or EXITS 9 (commencing with Section 7000) of Division 3 of the Buss ness and Professions Code and my license Is In full force and PARKING effect SPACES RCD D O Pwov.D¢o License Number LIc Class LIMITED TIME USE Contractor Date OATe O.TS ❑ amexempt from the IlLensing requirements as I am a P.D. TO 1 licensed architect or a registered professional engineer SIZE of No of INS: crust acting In my professional capacity (Section 7051 Bus- EXISTING BLDG _ BTORIHE S NAruwE mess and Professions Code) RCSENT use of BUILDING FINAL APPROVAL LIc or Reg No Date , /G C PPC HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS ` ONO LOT AND USE 1 hereby affirm that 1 am exempt from the Contractors License Law for the following reason (Section 7031 5 Busl ness and Professions(ode) no PARKING ❑ SPAC SS PROVIDCo 1 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) P RoroeED use OF BUILDING 23576A CONSTRUCTION LLNDING AGENCY OfF/GE ��[� 1 hereby affirm that there Is a constructionlending agency for the performance of the workkfor which � a S • 088 h this permit Is _ Issued(Sec 3097 Civ C) • . . • . . Lenders Name PROPOSED MAX occ Lenders Address PERMIT FEC 1 2 0 3-8 5 1 certify that I have read this app cation and state that the ISSUANCE FEE above Information a correct I ogre to comply with all County ordinances and State laws relal g to is Us construction, TOTAL Fee and hereby authorve represent Ives of this County to enter upon thea ve mentio d pr rty for Inspection purposes SEE REVERSE I OR EXPLANATORY LANGUAGE Signature of Perm tee Date s WORKERS COMPENSATION DECLARATION r� 76M444 CE 875 (280) MISCELLANEOUS APPLICATION 1 hereby affirm that I hma a certificate of cons+.nt 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 Compan> FOR APPLICANT TO FILL IN BUILDI-c ) -, CertiOLd copy Is hereby furnished L ADDRCNa C 1 ADDRESS . og LOCALITY Certified copy u fried with the county budding inspection v �Q NEAREST department LOCALITY rQ G _ pV/ CROSS ST _ t Date Applicant I. NEAREST t Lam' r ' Oie TRIC O UP TY H PRO 88ED HY CROSS aT CONS Ch RTII ICATE OF EXEMPTION FROM WORKERS j LEGAL - Y,<S'7 - Cl COMPENSATION INSURANCE + DESCRIPTION rLOT N0�7l_ eLoe% NAP Ia„W.r >_rvo - Ic rnuxl BTATC MAJOR SCCOND LOCAL a (Thu section need not he.com leted If the work involved S�1 No oR BLDae use :one SPECIAL sono moria p TRACT NOW ON LOT O by the permit u for one hundred dollar (5100) or less) f ti mH DP U 1 certify that In the I SaE of Lor M Ez+en Na BLDG cc performance of the work for which Ihu i � permit Is Issued I shall not employ any person In any manner wneR I ”. 0 so as to become subject to the Workers Com pensaUon Laws AI+. OCCUPANCY GROUP U W ADDRESS Date Applicant 0. N NOTICE TO APPLICANT If after making this Certificate of ci Tv Sri oL - OCCUPANT LOAD z Exemption you should become subject to the Workers Compensation provutons of the Labor Code, you must forth I APPLICATION FOR EXIT HARDWARE with comply with such provisions Or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION❑ No QQ Kt10W1 Eldeemed revoked P I LICENSED CONTRACTORS DF LLA RATION occuvwncv msPErnorr01 PQDIC DQVICQ$ hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT Icer ITEMS BeLowl No OF exlre e (commencing with SLction 7000) of Division 3 of the Bain ness and Professions Code and my license Is in full force and ' PARKING Rxlna effect SPACES REO Is v..v.DHD kicense Number Lac Class LIMITED TIME USE Contractor Date - DAYS DATx ❑ wo 1 am exempt from the licensing requirements as I em a TO licensed architect or a registered professional engme,.r aim OF ND OF INSPVCTOR S acting In my professional capacity (Section 7051 Bus- CXIST NG BLDG STORIES eiGNwrURC mess and Professions Code) VA PR A FINAL L POp O Y HBfi NT U6H OF BUILDING I V I LIc or Reg No Date C..! • �^/j, e • o e ING HOME OWNER BUILDER DECLARATION ON Lor wnO eH NO of E= Use BUILDINGS - t220-82 22O-82 1 hereby affirm that .1 am exempt from the Contractor s License Law for the following reason (Section 7031 5 Busl ness and Professions Code) NO PARKING ' BPACGB PROVIDED 1 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) RoPOSED USK OF BUILDING CONSTRUCTION LENDING AGLNCY I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is I Issued (Sec 3097 Civ C ) Lenders Name PROPOSED MAX OCC Lender s Address PERMIT FEE 1 certify that I have read this application and state that the above Information B correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to budding Lonstruttion TOTAL FEE and hereby authorve representatives of this County to LntLr up pov n arty for Inspection purposes SEE RLVLRSE FOR EXPLANATORY LANGUAGE Signati-re Of Permittee U Date WORKERS'COMPENSATIONDFCLARATION I CE 875 11 801 MISCELLANEOUS APPLICATION CE 075 I hereby affirm that I have a certificate of consent nsur to :alt COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION metre or a copy thereof of Workers Compensation Insurance or e certified copy thereof(Sec 3800 Lab C ) I fl Policy No Company ' FOR APPLICANT TO FILL IN 0.o4aD91 Ni O ❑ Certified copy Is hLreby furnished uILDINc ElDgH98 4509 Temple Cit Blvd, T.C. LOE"Lair j Certified copy is filed with the county building mspecl Ion 102A NE depart epettment LOCALITY AR95TCROSS ST Date Applicant NEw11e3T DISTRICT No GROUP "ERO.IESSITO BY CROSS 8T , OZ 73 CONST CERTIFICATE OF EXEMPTION I ROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK Io„wwr p"' (�,RCLC) STATC MAJOR SECOND LOCAL a (Thu section need not be completed d the work involved n0 O LOT USE ZONE SPECIAL CONDITIONS b the p ( ) Tgwcr Now on Lor L) y permit is for one hundred dollars 5100) or less ueE DF U 1 certify That In the SIZE OF LOT Ex[STING SLOG 0 y performance of the work far which this permit u Issued 1 shall not employ any person in any mannerof wnER- so as to become subject to the Workers Compensation Lawn AIL building Gla OCCUPANCY GROUP tU DRcsa �9 Date Applicant y NOTICE TO APPLICANT If after making this Certificate ofrr 4509 Temple City =d. , T.C. 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 TRAILCR USE❑ GEOLOGY INSPECTION NOS KDOW� ❑ deemed revoked ❑ pec LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY .HRMIT Q (LIST ITCMS 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 PARKING eKlna effect a SPACES REG O PRovIDCD License Number Luc ClassLIMITED TIME USE C2ntractor. Date DwTS o Ta 1 am exempt from the licensing requirements as I am a w licensed architect or a registered professional engineer SIZE OF nO OF INSPECTOR S acting In my professional capacity (Section 7051 Bus- XIBri NG 0 D _ aro Rlea SIGNATURC Ines and Professions Code) P GENT USE OF tauILDING Office FINAL APPROVAL O� �71 v Lac or Reg No Date .10 /� aJ HOMEOWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Buss ne,is and Professions Code) NO PARKING ,. y /, 3 Z 3 rI rl SPA Ea PROVIDED L Y ❑ I as owner of the property, will do the work and the • • • • 88 structure is not Intended or offered for sale (Section 7044 Business and Professions Code) ROPOSED USE OF BUILDING 'Office CONSTRUCTION LLNDING AGENCY 0 8 08-83 1 hereby offset that there as o construction lending agency for the performance of the work for which this permit Is Issued (Sec 3097 Civ C) Lender s Name T PROPOSED MAX OCC Lenders Address � PERMIT FEE I certify that I have read this apphcation and state that the above Information as crrecl I agree to comply with all County ISSUANCE FEE ordinances a aws relate to budding construction TOTAL FEE end here aur nze epr Ives of,t County to enter p it abc men on operty to spection pu poses SEF REVERSE FOR EXPLANATORY LANGUAGE Signal a of P tee e WORKERS'COMPENSATIONDECLARATION ' CEG 4" 76M MISCELLANEOUS APPLICATION \� 1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �Pnsure or a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800,Lab C) Policy No Compan) FOR APPLICANT TO FILL IN wBUILDING DD¢¢ae ❑ Certified copy Is hereby furnished olNa LOCALITY DREee Certified copy D filed with the county building Inspection NEAREST department oc ITT --r (� cRoee Sr Date Applicant I ICA wRQ9T /^� DISTRICT NO O P TYP¢ PRO 6H0 ¢Y CONS 69 CERTIFICATE OF EXEMPTION FROM WORKERSLEGAL r COMPENSATION INSURANCE 0ESCRIPTSort LOT No BLOccIDNYrA y �wP �t,w CLe� ¢TATs MAJOR e¢eono ocwL d no OF eI DGs 8 (Thu section need not be completed if the work mvolved TRACT NOIv oN Lor USE ZONE 9P HCIAL CONDITIONS by the permit u for one hundred dollars ($100) or less) ^ EXISTING 112E OF LOT USE OF 6 DLO6 -2/ Q I certify that In the performance of the work for which this VV O permit Is Issued 1 shall not employ any person in any manner SERACCEPMAZ Ur so as to become subject to the Workers Compensation Laws �r�'1L C O OCCUPANCY GROUP W ROD Ess i O / r CL Date Applicant N NOTICE TO APPLICANT If after making this Certificate of ITY T TEL -11187 OCCUPANT LOAD Z Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE Compensation pro"sions of the Labor Code you must forth - wlth comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION NO SPCC KnoWl E!deemed revoked ' LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ 1 hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) No OF ¢xIT¢ 9 (commencing with Section 7000)of Division 3 of the Bust ness and Professions Code and my license Is In full force and PARKIN O effect SPAt¢S RED D PRovlo¢o License Number Lie Class LIMITED TIME USE Contractor Date AT. - OAT. El 1 am exempt from the licensing requirements as I am a TD I censed architect or a registered professional engineer SIZE or No oP INSPECTOR e acting in my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES SIGNATURE mess and Professions Code) FINAL APPROVAL HOENT U6E OF BUILDING Lie or Reg No Date HOME OWNER BUILDER DECLARATION ONO of Ex ISYING 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 a 139. ness and Professions Code) NO PARKING -SPACES PROVIDED co ❑ 1 as owner of the property will do the work and the xQ 1,23-85 structure Is not Intended or offered for sale (Section 7044 Business and Professions Code) oPoi¢D USE of BUILDING CONSTRUCTION LLNDING AGLNCY / F I hereby affirm that there Is a construction lending agency LO _ for the performance of the work for which this permit is ' Issued (Sec 3097 Civ C ) Lender s Name PROPOSED MAX OCC . Lenders Address PERMIT FEE 1 certify that 1 have read this application and state that the ISSUANCE FEE , above Information Is correct 1 agree to comply with all County 'ordmances State laws r tas to budding construction TOTAL PEE and here onre re r �Synta[I s of this County to enter u on t e t try for inape on ptirp.,;p SEE REVERSE FOR EXPLANATORY LANGUAGE p y Date WQRKERS COMPENSATION DECLARATION 76M444 M ISCELLANEOUS APPLICATION CE 675 (11 84) , I hee, or atfert that 1 have a s'Compensation oG consent to ,elfor COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION msire, or a certifinte of Workers'Compensation Insurance,or a certiled Copy thereof(Sec 3800, Lab C) Policy No Company FOR APPLICANT TO FI LL IN 'BUILDING ADDRESS _ / Certified copy Is hereby furnished BUILm AOOR¢Sa rvG 4509 T City LOCALIT'Y Certified Copy is filed with the county building inspection LOCALITY NKAREaT department CROSS ST Date - Applicant Eww¢nr DI.T cr N a uP Tr Pe PR Ea BY CROSS ar Lower Azusa � conar CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �� COMPENSATION INSURANCE D¢SCR IPTIOn Lor No 'BLOCK A .DNwAY _ - _ Now (CIRCL.) arw T¢ MAJOR SEC&D LOCAL NO OF BLOBS (Thu section need not be completed if the work involved rwwcr Nov ON Lor u4¢ zoNE SPE Iwl CONDITIONS by the permit is for one hundred dollars (f100) or less) uaE of "1 I certify that in the performance of the work for which this Size OF LOT ¢xI.TING SLOG permit u visited, 1 shall not employ any person many manner WNew Delia A . Serna s1 m as to become subject to the Workers Compensation Laws AIL OCCUPANCY GROUPS L> O_ _ o Dale Apphcam ADDS KSaSame _0877 NOTICE TO APPLICANT If, after making this Certificate of clrrSaMe TIDE RRRXRRAA �.OCCUPANT LOAD H 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 pi 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 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 PARKING pPACEE REO D D PROVIDED License Number Lic Clnss • LIMITED TIME USE Contractor - Date DATM AT. 0 1 am exempt from the licensing requirements as I am a PwoR TO licensed architect or a registered professional engineer SIZE INSPECTOR a araRl¢S .IwruwSacting m my professional capacity (Section 7051, Bus- ExI GBLDG mess and Professions Code) FINAL APPROVAL O V A L Lrc or Reg No Date PRESENT USE OF BUILDING office HOME OWNER-BUILDER DECLARATION NO GF EXISTING BUILDINGS ON LOT ANO 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 ;@654L1 A I, as owner of the property, will do the work and the SPACES PROVIDED ' p x y, structure is not intended or offered for sale (Section . 'F.� •- 7044,Business and Professions Code) CONSTRUCTION LENDING AGLNCY PROPOSED USE OF BUILDING off ice- `` •+,� ` ` \ `; - ' I hereby affirm that there is a Lonstmctian lending agency for the performance of the work for which this permit is �- issued(Sec 3097,Cry C) - •.� ;r \"^� `1 , \ ` Lender's Name PROPOSED MAX Bee I 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 lass relating to building Consruction, and hereby authorize representatives of this County to enter TOTAL. FEE upo the above-me one roperty for vnspec n purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o Permittee Date - N WORKERS'COMPENSATIONDECLARATION CE 875 (Z B01 • CE 876 MISCELLANEOUS APPLICATION 1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION - icire or a certificate of Workers Compensation Insurance or certified copy thereof(Sec 3800 Lab C ) �/ Policy No Company FOR APPLICANT TO FILL IN BUILD.-- F] wane 7 ❑ Certified copy u hereby furnished ouuowe r ' ❑ _ ADOR¢aS -/O TCw. LL LATS ISLY✓J Loc AL[TY _ Certified copy u fled with the county building inspection department oewLirY M 7 C' '� cwoaa er Date Applicant ARKST 019TRrcr o 0 our Tyre Ino o Hr CROa6 aT 0 rJ� �r� A (/V � 0 Z— CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL {/ COMPENSATION INSURANCE Daac RIPTION LOT No ¢LOCK MAe ,.1...A � Y NO Ic uCte) STATE MAJOR TRwCT NOON aeCON LOCAL d (This section need not be completed d the work involved NO W OR BLOT LT us¢ ZONE SPECIAL CONDITIONS 0 by the permit u for one hundred dollars ($100) or less) _ - USE OF 0 1 certify that m the SIZE OF LOT Ex[STING ¢Loc CMZ Q y performance of the work for which this O permit is issued, 1 shall not employ any person in any manner I ArCINER 0A e so as to become subject to the Workers Compensation Laws .�[ OCCUPANCY GROUP _ W wool Egg _ Q O/� I s -�`, - N Date Applicant pp NOTICE TO APPLICANT If after making this Certificate of CITYAl QZ1< ��1 TEL$) d �(I"I ) �OS � OCCUPANT LOAD Z Lxemption you should become subject,to the Workers Compensation pro%is[ons of the Labor Code you must forth APPLICATION FOR - EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION O No Spec Knowl ❑ ' deemed revoked LICENSED CONTRACTORS DLCLARATION occurwrvcr inaP¢rnPanic Devices aN ❑ 1 hereby affirm that I am hLensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BULOW) NO or EXITS 9 (commencing with Section 7000) of Division 3 of the Busl ness and Professions Code and my license is in full force and PwRKINe effect SPACESRao O reo.lo¢o PA*K[N License Number Lic Class LIMITED TIME USE Contractor Date DAT. OwTa ❑ I am exempt from the licensing requirements as I am a TO licensed architect or a registered professional engineer SIZE Or INaP ros n acting In my professional capacity (Section 70c51 Bas- ¢xlan rve BLDD "o Fa 9I wruea No or mess and Professions Code) G R J.I!L FINAL APPROVAL 7 P HMT USE OF BUILDING L r-C.- Lic or Rea No Date HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS ` ON LOT AND USE _ I hereby affirm that I am exempt from the Contractors _ License Law for the following reason (Section 7031 5 Busi ness and Professions Code) NO PARKING PACES PROVIDED • • • • • • • g� Sp G'1 7-85 ❑ 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) jwro.913 4-USE OF BUILDING C, �r R CONSTRUCTION LLNDING AGENCY '.l I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is f\ Issued 'Sec 3097 Civ C ) (/ Lender's Name PROPOSED MAX Dec 1 Y Lender s Address PERMIT FEE 1 certify that I have read this application and state that the C 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 represeatativ s of this County to enter upon the above men ned We y for inspect purposes SLL REVERSL I OR LXPLANATORY LANGUAGE _ Signature of P-01Ilee !//at ' "' " "J " ' " "' "" """ CE 815 M ISCELLANEOUS APPLICATION ce CTs t+ as I �ee -i atf3rm that I have a certsftmi or OnsLnI to Ulf COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION l msure nr a Lendreale of Workers Comminution Insunnae nr " i •I a Lcrtified Lops thereat Sc, 3801) Lab ( 1 ❑ Polio No _t ,mean) _ -- FOR APPLICANT TO FILL IN Bu uolNa �D q `/.DDwESt Ceridied Lops Is hereb% •urmshW X BUILDING 4509 Temple Cit Blvd. LOCALITY GORE., I I Certified x p% i%trled with the ")unit ouudmL tmpeLtson LOCALITY N.....T department Temple City CROSS ST Date _ \nph an[ IEAREsr DISTRICT No cwD P TYPE P csseD BY CROSS Sr LOWeI' AZllSd Ave. CDnaT CER rIf it \TL OF L\E\IPTIO\ FROM WRKERb L[O.L C,)\IPF\S\TION l\SL R\\LI DEf cwl•r On LOT VD BLOCK ,4 u,t.• yr1Te MAJOR SECOND LOCAL (This sectmn need not NG DF LOT .D. N he hundred ll the n,d, mt less I I-R.c- Iow in LDS US[ •GnE ..P�cuL CONDITION. by the permit n [or nne hundred dollar ,SIUDt Or letsl IuSE DP I I I fI=L JF -OT a\If TIND BLDG + 1 -ertsf\ hat in he Ov,nrman,e t he , , a , - %Inc'( his �COpeCC' - Permit B Issu,d I ,hall ,o, .mplo, ant e-w i ,int mann,• GwNeR John Allen = so as v heL nne 'u btu n the `\orAe•s ,noe,vno, I Awa OCCUPANC ]ROUP Date \orhas,t OO-Ess 4509 Temple City Blvd. I� - _ NOTICL TO %PPLI( \\T I' n v -t.l. r_ • _t,arc It $I— T No626-443-44371 I-'CCUPn�V-L--,1CE%empuO, toll nanld heLOM- m^ILL a' hL l\,+-¢,•, APDL Ca'IC%' ='c -r ' -IGgrn ,-- L mrLwtion ^m tsn+n, n h, I Thar +de s ,a must ❑v,h - _ Rah -0111'1% ,it, u,lt 'nn rte m, nn ,rnu diad hL _. _o a 1_ sEoury N-rte_- O _ NO $DNC \ l`, Deemed L' .La "`- LI, r\SFD I O%I R\( TORS DL' L 4R \TI,'• Dcc ar An cT nv[r,oN$ P3n a Ce§'r=% ❑ I he•Lb, a'ITm lit, I aln '¢-,ted unde-"reLrvon+o C IAWL• >.reTY .eRwlr — usr Ire a 9e LO it I 9 ,uann wuna ,uth 4a ton -000t al Dnnlon _ +I he liva — I No or "IT9 - n,ss and P-+IL„n,n, I ,I, Ind i % It,,is, „ it i I , n. utd Cl Ll PARKING I Lces w[DG I •wc noED LILLnse \uml'L• LL l'n, e-e— LIMITED TIME USE �.. I Ain .%ampt -Mn he hLn,mL Latiu, nents Is I At" I 1 bLemed ar,haLa ,r i -eat,tered —ale,stond .ncinLdr -Ize Or O �- INSP[DTow s e aL[tr_ n nIa , rr,i ltd ,r, n -"•. fill, YVi�TIV� 9-. -Dae- s,ONwraw[ o me,,.to '-Inluu n,( ,d., L L n RL^_ \a _- __— _- _ ___ D, L _ _=¢Nr use or BUILDING APDROV AL NG _ c 1 1 I1WIL Ow\I R MILDER DELL\'t \FIt)\ NO or [r,STING BUILDINGS '1 A ON LOT AND Vf[ VY I hereby at-nn dui 1 am L\Lmpt tmm ,hc Con[nLton 1 LlLense Law to• Th, rea,un ISL,non -"_I , Bust W1 FFE ness and P•atesssons Codei NO P.RKING s6.1 1 as ,%net or the proper[% will do hL And, Ind lhL 'P.ces .wovIDEDI-Q_IQ %true Ura is not im,.ded or olttad I,rc ale ISeanon !J tt 1 7041 8u,im,s Ind PnuLsaon%(-od,) l0\SI RL( 710\ LLVDI\G lid \I % a rwoPO%EO USE Or BUILDING ' I IlLrLbt arfant that there Is I LonslolLtion lenthnit un-n,% I 1 for (h, pLrturmanLL of Th, �,nrk for wluth his I'Lrmn is ASULd ISLL 304' 0, f t LLndLrI's nnL P ,- Lender s \ddn+s PROPOSED MAX Oce I Lerttf% that I have read thus applumiton and ,Iatt. that the PERMIT FEE 25.00 abote mformiation I%LorAw I IEree to Lnmpl) Nith all Coun[v ISSUANCE FEE orduan,c% and State laws r,latina to budding Onstructsan and hereb% amhorae representarn Ls or is Lounty to enter TOTAL FEE 0 L 1 I upon the Abo e in ntionLd property tot penton purposes SEC RL\ERSF FOR E\PLaNATORY LAVGU%GF h Sion nurc al VermOt,.e I� 1 ,sJ r WORKERS COMPENSATION DECLARATION 7fiM44d M 1 SC E LLA N EO U�SI�9.� L!cf. 11 O N {� CE 014 It l 841 P LI 1 hereby affirm that 1 have a certificate of Consent to stlf COUNTY OF LOS ANGELES — '3i1IL�ING AND SAFETY DIVISION maim, or a o•taticate of workers'Compensation Insurance,or a certified copy thereof(Sac 3800,La C 1 Policy No _—Company FOR APPLICANT TO FILL IN 'Z BUILDING CeTtdied Copy is hereby fu EuaLD anO SO T C_\� woowuS Lo cwur 1 Ceeptifie Ct Copy n filed with th n u utspectcon LOC44ITY Temple City NEAREST CROSS ST Datil Applrant Nuwur DasrwGRo ITV' Oc[uEO By CwOtt ST cont CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE Da.cRarnON Lor No Elocx N^• '^""^� STATE MAJOR SECOND LOcwl nil or BLDas No cucu (This Section need not be completed d the work involved rRAcr Now ON LOT USE zo NE IPE clwl CONDITIONS by the permit Is for one hundred dollars (5100) or leu.lutEnnG BLDG or SIZE or Lor 1 I cendy that m the performance of the norl• for which this Exlt permit ss issued, I shall not employ any Person m any manner OWNER so as a mbJect lithe Workers' Co/m�pea`s`auo``n Laws MAIL 1 OCCUPANCY GROUP I Date htl ADOREI J NOTICE O PLIC ati If, after riul.ing ,hp Cerzd'cat, Slit Nol OCCUPANT LOAD = Exemption you should become subject to the WorkersAPPLICATION COR EXIT 4AROWARE Compensation provisions of the Labor Code you must .orthIt - 1 with Comply with such proSmons or this permit snag be m TRAILER Jf6 _ GEOLOGY iNfPEc-ION _ No Spec Knows deemed retoked LICENSED CO\TRACTORS DECLARATIO\ oc cu PAN c+ Irvvec-long FaniC Devices I herebs caftan that I am licensed under prosisionsoi Chapte• SAFET" PERMIT — (LIS- ITE+,S EE.ov I 1 9 (commencing with Sec,wn 10001 of Dtsason 3 of he Busa- — No OF axI-. ness and Professions Coat and ms license is m LB orce Ina InleC Pp RNING 4aPACEs RED D � Pw DVIDED _ License \umbe \ L L Class LIMITED TIME USE A Contractor DateTe 1 am exempt .tom ,he uLensing -equucments as I am a 1 licensed architect, o• a regrsterea pro,essional enc_inee• SIZE OFNc OF INSPEc-OR s e accinE m mL processional `apa,',\ Se, ion 051 But EXISTING BLDG 910 SIGNATV Ra mess and Proiessions Coda € PR EaErv- USE or BuumNa FINAL APPROVAL Llc Or Reg \O Da HOME OWER-BLILDER DECL 4w,-IO\ No OF ExunNa BUILD,... d0 ON Lor AND USE 4 I hereba affirm that I am exempt rom the Cont!20or l OIII 1 License Lau ror the followmg reason 'SeLtion -031 5 81111- ness and Protesssans Code) No PARKING lO 'V 'II Ii I-I_i 1 as owner or .he propern ndl do ,he cw ork and the frc.. ... f PR Dvm ED structure is not intended or offered ror sale 15ection - - t 7044 Business and Protesssons Code I P C04STRL CTION LE\DING AGE\C) a PROPOSED u.E Or BUILDING I hercbt affirm that there B a Lonstruc ion lending agents 1 for the performance of the wo for uhi,.h this permit 4 issuedI Sec 3097,Cw C) Lerida s Name PROPOSED MAX OCC Lenders address i 1 I caufs that I have read this application and state that the PERMIT ran 25,00 above information is correct 1 agree to comph with all County j ISSUANCE FEE ordinances and State laws relating to budding Construction 1 and hembv authorize represematnres of this County to enter TOTAL FEE 25, upon the above-mentioned proper[% for inspection purposes I SEE REVERSE FOR E71PLA\ATOAY LANGUAGE v Signature of Permittee Date ' ) I ( , WORKERS COMPENSATION DECLARATION 3DPW'2190 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES I BUILDING AND SAFETY DIVISION ( Imigure,Or a certificate of Workers'Compensation Insurance, or Ia certified copy thereof(Set: 3800, Lab, C) Policy N0. Company FOR APPLICANT TO FILL IN BurLDING WUILDLNQ ADDRESS ADDRE95 I 8 Certified copy is hereby furnished — ,L t Certified copy is filed with the county budding mspecti nP NEAREST departmentCROSS ST Date Applicant SI N OF L O OF NOW ON LOT DISTRICT NO GROUP TYPE MlOCeafED sv corvsr CERTIFICATE OF EXEMPTION FROM WORKERSTRACT BLOCK LOT NO t I COMPENSATION INSURANCE •� I�""AT No 111. STATE MAJOR SECOND LOCAL (This section need not be completed If the work involved ASSESSOR MAP BOOK PAGE PARCEL LlBE ZONH BPCGAL CONDITIONS I by the permit is for one hundred dollars (SIOO) or less.) Winter TEL NO f I certify that in the performance of the work for which th permit issued [ shall not employ any person m an mann is so as to become subject to the Workers Compensation Laws °mss OCCUPANCY GROUP ( Date Applicant U ZIP NOTICE TO APPLICANT If after making this Certificate z� OCCUPANT LOAD of Exemption you should become subject to the WorkersPLICATION FOR Compensation provisions of the Labor Code you must forthwith EXIT HARDWARE comply with such provisions or this permit shall be deemed TRAILER use❑ GEOLOGY INsPEcnc,N❑ No Spec Knowl ❑ revoked F� LICENSED CONTRACTORS DECLARATION OCCUPANCY INBFlCTION L.d Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY FCRMIT❑ (LIST ITEMS BCLOW) r I 9(commencing with Section 7000)of Division 3 of the Bol ND of ExITS and Professions Code and my license Is in full force and effec 8me O uH ess PARKING RCD O PROVIDED License Number Lit Class Aelm4L OL SPACES ( , I Contractor Date LIMITED TIME USE I p ❑ I am exempt from the licensing requirements as I am a FROM DATE TO DATE ` hcensed architect or a registered professional engineer a acting in my professional ca acity(Section 7051 Business "zE DF NO OF NSPECTOR S (� and Professions Code) p fxrsnNG BLDG I BTORIef LGNATURE. Lic or Reg, No Date PReaENT USE OF BUILDING FINAL APPROVAL 4v.)- HOME fHOME OWNER-BUILDER DECLARATION NO OF"firl"ING BUILDINGS DH LAT AND USE , I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 70315 Business and ( ' , Professions Code) !W PARKING ❑ I as owner of the property will do the work and the SPACES PROVIDED structure is not Intended or offered for sale(Section 7 POSED t E OF BUILDING Business and Professions Code) CONSTRUCTION LENDING AGENCY ffirm re I hereby athat theIs a construction lending agency for /yTI/� the performance of the work for which this permit is Issued ( , (Sec 3097, Civ C) PROPOSED MAX Occ Lender's Name FPLICANr rBwr) TEL NO Lenders Address D "a• ( I certify that I have read this application and state that the above information is correct 1 agree to comply with all County PERMIT FEE I ordinances and State laws relating to building construction and hereby nuthonm representatives of this County to enter upon ISsvANCE FEE 4 the above-mentioned p ert y for inspection purposes. I TOTAL FC! 6 SEE REVERSE FOR EXPLANATORY LANGUAGE u , slgnaiure of Permr°ee DTte