HomeMy Public PortalAbout4516 TEMPLE CITY BLVD_Miscellaneous__ tWRk£Rs COMPENSATION DECLARATION CE76M4"875(11 84) MISCELLANEOUS APPLICATION {�
CE LJ
1 hereby insure, ce
d certificate
that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a rtt ificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,lab C)
Policy No Company FOR APPLICANT TO FILL IN coo see
Certified copy is hereby furnished uamwa Lo cw LIrr
AV Bw Hee
Certified copy n filed with the county budding inspection LocwLITY nEww HaT
departmentcwoee Vi Cal— Sr
Date Applicantcow Her
DISTRICT No a ou• rrP¢ Pw Oe9s 90 By
cwoee ST f cower
CERTIFICATE Or EXEMPTION FROM WORKERS'
LEGAL O4
COMPENSATION INSURANCE BEacRIPTION LOT NO BLOCK rMAP ;cone�'
STATE MAJOR SECOND LOCAL
No OR
eLOas
(This ion need not be completed d the work involved TwwcT Now oN LOT USE :ONE a.ecuL cowo mows
by the permit is for one hundred dollars ($100) or less) ueE OF
SIZE OF LOT TING BLD
I certify that in the performance of the work for which this
permit is Issued, I shall not employ any person in any manner W Leo
so as to become subject to the Workers Compensation Laws m OANCY GROUP —� o
MAIIt L
Date Applicant AD OR SeaAF
U
NOTICE TO APPLICANT If, after making this Certificate oC SIT OCCUPANT LOAD
Exemption, you should become subject to the Workers
_110 k
Compensation provisions of the Labor Code, you must forth- _ APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER ueH ❑ GEOLOGY INSPECTION ❑ NO Spec KnOWI
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 Durston 3 of the Buss- No OF HKITS
ness and Professions Code, and my license is in full force and
effect PARKING
SPwc¢a REO o � Pw ov m¢o
License Number Lm Class
LIMITED TIME USE
Contractor Date JE2DAT. DArK
❑ 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer arse of No of INe.Is crow a
acting m my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL /
gNT USE OF BUILDING
Lic or Reg No Date ¢a
HOME OWNER-BUILDER DECLARATION No o exiaTlNO au u.DlNGe
NO FEE
ON LOT AND USE
I hereby affirm that 1 am exempt from the Contractor s
License Law for the following reason (Section 7031 5, Busr 1]QI]Ij-1]1]1]1 �t� d�91
ness and Professions Code) NO PARKING
0 I, as owner of the property, will do the work and the SPACES PROVIDED 63x1 17;17
structure is not intended or offered for sale (Section - O --
7044,Business and Professions Code) \
CONSTRUCTION LENDING AGENCY PROPOSED USK or BUILDING N
I hereby affirm that there is a construction lending agency
7\
for the performance of the work for which this permit is
issued(Sec 3097,Civ C) -
Lender's Name
PROPOSED MAX Bee
Lender's Address
PERMIT PHH
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,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned properly for inspection pu s
SEE REVERSE FOR EXPLANATORY LANGUAGE
n
Rte ir/ -
Signature of ermitte Date
WORKERS'COMPENSATION DECLARATION ICE 875
' CE 675 (11 64) M ISCELLANEOUS APPLICATION
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)
Polis No —Company Bml.mrvo
Y P FOR APPLICANT TO FILL IN we DRESS
ElCertified copy is hereby furnished arum No lbTr" LOCALITY
wDORH
Certified copy is filed with the county budding inspection OCALITrT 4> NE ww ear
department �HOLL tri Cq 975cwoa3 Sr
Date - ApplicantCROSS er Lo trL A'].0 C� evev� DISTR icr y� o o� coxsr , / aae¢D er
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O` V
v
COMPENSATION INSURANCE DESCRIPTION LOT xo awcR . IcIwcLE)wr STATE MAJOR SECOND LOCAL oP
NO or BLDaE
(This'seclion need not be completed if the work involved TRACT Now on Lor USE zONE
SPEcuL CONDITIONS
by the permit is for one hundred dollars (S100) or less) USE or //�
SIZE or Lor Rw.TING BLDG G1 ti
1 certify that in the performance Of the work for which this o
permit u issued, I shall not employ any person in any manner OWNER A9 !EVA i- ^/ v
so as,to become subject to the Workers' Compensation Lags �itAIL OCCUPANCY GROUP a o
Dale Applicant ADDRESS /SO N.SI�N ,-1L TWL
PP cD
NOTICE TO APPLICANT If, after making this Certificate of Crtr A rLe A.Ii Cyq.9loo(�NO f/p_yyL_ O o OCCUPANT LOAD O_
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provisoes or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION oeeu PANcr INSPECTION ❑ Panic Devices
I hereby affirm that 1 am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busr awrerr PERMIT E:] (LIST Irwre Beww)
NO or ExITE
ness and Professions Code,and my license is m full force and
effect c.y/-/[.{_ PAG INS RED D PROVIDED
-r-� arwCIN
License Number Lie Class S o nr0 i�+ /'r J n-A w/
LIMITED TIME USE
Contractor Date DATE DATA
.nor ro
I am exempt from the licensing requirements s as 1 am a
acting i architect or a registered capacity
professional engineer Eor SO 1 mire Crow S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG arowl¢S elanwruRE
mess and Professions Code) FINAL APPROVAL �jb1J�
Lie or Reg No Date
PRESENT USE or BUILDING L
MtY/GA.J oe Q LS ...�.�. ,..r
NOME OWNER-BUILDER DECLARATION No or exlennG Bin LDwos - "'y
USE p
I hereby affirm NO Lor ASCO that I am exempt from the Contractors
License Law for the following reason (Section 7031 5, Busr
ness and Professions Code) no PARKING
1, as owner of the property, will do the work and the SPACES PROVIDED -r1�6c , _li = 7
structure a not intended or offered for sale (Section -
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE Or BUILDING
I hereby affirm that there is a construction lending agency LS 7—AAA^-7_ o
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 ,Ofl r
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laus relating to budding construction,
and hereby authorize representatives of this County to enter TOTAL FEE 6 p-(�
upgn th ve mentioned p y for mspecuon purposes
---� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature
1
I
UUHLLHS (OAIPLNSATIONDCCLARATION
CE 875 111 Bdl _ MISCELLANEOUS APPLICATION
CE 875 '
I hereto ati'um that 1 have a ceritficamCompen of consent to x¢ COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Workm'Cotnpennuoa Insurance,or
a certified copy thereof(Sec 3800 Lab C)
polies No (ompom FOR APPLICANT TO FILL IN cu1LD IND
I ADnwcSa �/c/�z� s
Certified Lopv is herebv furnished �DILD IN6 LOCALITT
D
ADwccc-4' IL12 " VD i
Certified copv u fled with the counts,budding wapectioX LOCALrrT &(K �� O,l-r cwoes n
department
Dvc _ 1pplintitNCAweaT DIST..CT No ewouP rrPC . ceeaeD a.
ewoaa sT `6 p i•r eoneT
( I R 111 R ATL OF E\EVPTIO\ FROM WORkERS Le Dd
.L , J"
CD\IPE\S\TION INSURANCE use.. LOT No cLccN •... ....
ND' Ic.c LAl STATEMAIOR sccDnD LocAL
orinvolvedNo or cLDca
ITh,,
•:cutin nee i im lie completed If the w k TR.CT NOR On _oT USX joNelfPeelAL CONDITIONS
In the permit Is wt me nundreu Jollars (SI00) or less ) Dr /J I
sr_c or Lor I uae axis-IND CLD. G '�
^-^Ih ,tut In hL ^^•IollnanLe I'I ne work `orAC
wmeh I L
�Lrmn n Issued I sit til uu ^mrto\ •ns 7e•son to an) mann ORNew OF Ll L'l�C2II H I L O
11 11 Ili hL milt .u1nL a Ih, 'lorne•s Compensation Laws MAIL l' CCCJPANCv GRCUP
h„Ie _ __ \CC1LL Int A...... wrio tc- WP I .�
- TCL
VOTICf FO APPLI( AVT If atm: mixing ,Ills Centficste of GT No ( I(f�l-4 Et ZI CCCJPANT LOAD
I \emotion oil should benme su°lec• to the Woriers
C n'ncnsiu)n +fn,sion, al le L-Lwr Code \ou must forth APOLI ATION =OR EXIT ARLWARE
sl h Lmmmh It WE silt.I pro'muns or ,its pernul shall be -ILAUCw USE -' Oco LOcr INvcc-ION — VO S°e6 Knowt L
�Ir nLd LwkLJ — — I
1 1( I NSI U(0\1 H\( TORS DE( L\RATION oc cu PANCT INvec-ION r-, °3nlC Devices CI
I ht. IIIc ohms ILI, I am hc.nsed ince-provlslonsof C'saule SAP:-T .CwMIT (LIST ereMe De-ow) - -
f o commegom \Loh Sec ton -0001 or Division 3 of the Busy .o o• X.ITI
nes, and n mt,,ons (,oc .oc r\ Iocnse Is in ull force a
Name C= DAS_:le/s'S CIA
PARKING RCo o .wOviO CD
I. .Ilmns - - - - I s s. -
14��ZS �R IaPAcca
( LIMITED TIME USE
Ill n n r - _ -- 1,:il ...a o..e
I im cse opt rom he ILeisine eautrements as I am a I..D
hLeosee arLnue o a EZIS e•ed protesslonal enpiule• arse o. TIO o. IN.-Kc-on s
3L,me In nn pros Lsvundi .araun iSec ton 70'1 Bus Isrs-Ino eow
Loe STlea SIONA-uRC
mess and Prolcsswns(oue /
FINAL APDROV AL
I it. It HC: \•II Date •R(ae MT VaE O. RVILD IM6 / V L
110111 011\FR dl IL)ER DCCI \RATION NO Or EXISTIND cwLDINDa O IU B
ON LOT AND uae rl'
I I hLna\ Ilium UM I till opt t Om the Contractors s I I
I cense I Iw for AIlL InllO\\ine Clsun ISutron 7031 S Bust
ness Ind Protessions(.odLl J.0 .ARNIND
1 as oane• of the prope•t) \\dl do the work and the SRwces .wovIDCD - - -
structure Is not Intended or offered for sale (Section
�I44 Business and Prolessions Code)
(ONSI RU( I ION I LNDING \GENCI PwoPoaeo uae or eu1LDlND
I IlLreb\ affirm that [heft Is a Lonstruc[ion lending agency _
fur the I,erfornume of (lie nod for which this permit is -D >.
nsued ISee 3097 Civ C I
I ctule-s Name
PwewoeeD MAX Dec
I Llultr s \ddress
III I Leruly tlut I have read Iles apphuhun and sum PERMIT PEE that the ,f,
ahuve infurmatnm iSLnrteLt I agree to mmpty with aH County ISSUANCE Ree
dimnm and State laps rebutrg to build mnstmetton,
nd hereby author 1: ttpttsentatwes of this Coun[y [o enter TOTw� Ree 25. 00
L[I.PnIlf"r
mspes.hon purposes
SvQ SEL REVERSE FOR EXPLANATORY LANGUAGE
igna
WORk.LRS CUhll'LNSAIIUV U!( I AR.LIIUN p1f�„1,nPvn ,u MISCELLANEOUS APPLICATION
Zi hcreb%'affirn Ihat 1 Ila%L 11 LCINIL,tlt (It LtRnLnl It) .L11 COUNII Of IOS ANGFIf_S BUILDING AND SAI ETY DIVISION II
I- Iitsere qr a Lertil lean OI Workers (um Ill.its I tint In%u nliLL or
a cell led copy thereof ISet 1800 tall C I I
a Policy No _ Company / FOR APPLICANT TO FILL IN ADDRESS
BBuiLo1 c/ R LR-�
(erlifieJ LOp) Is hcnby hunulled LocALITr
Certif led cop% I% IIlLJ Willi IIIL counrL build. Ik In p Loon aEA
Tv ' ZI fj�y
I
department Q v CROSS ST
Date _ App11L Int SIZE OF LOT O OF BLDGS NOW ON LOT GIST, DT NO, OROUP TYPE ESEED BY
(ERllt I( All OL EXLMI'IION I RUM \\ORL1 I(ti Of/ f coNeT '
,J (OMPENSAIION INSURAN(l rnACT BLOCK Lor No R.,V.1 lJ
mII14u STATE MAJOR SECOND LOCAL
(This stclion Illtd not Ilk toinpicled If Ilk w Irk Ilnol%ld ASSESSOR MAP BOOK PAGE PARCEL IMZONE BPELIALCONDITIONS t�
b) Ilk Strout is for Out hundrlJ dollar% Is RHR DI IL%%1 At
I cLrui) that Ill Ill, plrl OrnlmLL All IhL Nork u11 Uhith till+ OWNERS / _ �Q ,ZL n%1Y7�� —� I I
7 /�f
Ix.rmll IS uwLd I %hall not un plot ury pLl w+n m utL mmntl
so 1% 10 bLLonk %uby,LI ID Ilii WOILLFS I 0IIII1tIh1110I1 I IN% ADDRESS O_ ^ OCCUPANCY GROUP rr;
DaleAppllLant _ _ CITY _ 1 ZIP R
NOTICE TO APPI K ANI II Iw Ili k ung 11,1% ( Ln IRI. uL _ _ OCCUPANT LOAD
Of IALntPUOII LOU %huuld beL011ll %ublLLl to Ilk WnikLis _ APPLICATI1N FOR EXIT HARDWARE
(ompLIisatio1 prm imons All Ilk LlhPrl 01h. 101111111%1 I'll 1111
comply wish %uLlt proLulon% Or flu, ptrnul %h All hL JLLnkJ TRAILER UeL❑ GEOLOG. NSPECI1ONI_l No Spec Knowl ❑
re%oLed
OCCUPANCY INSPECTION Panic Devices ❑
LICENSED CONTR AC FORS IN(I All \IIUN
I hi.l aft Arm ill It I un IILLn%ed undtr pr0%I%101h 111 ( 11 plLr SAFETY PERMITO LAST ITEMS BELOW, -
_ i 9(Commenting\Lith SCLIion 7WBI4 On 1%111111(At Illi BusmLs% NO OF EXITS El
.. and Professions(oJL and my IICLII%C n In lull Io LL uld 040
PARKING RED D � PROVIDED D
- License Number Lk ( IIs% / - SPACES
_ fisc/
1 (t„urktor DIk �[ / LIMITED TIME USE
DATE DATE
❑ 1 1111 e%LJnpt from the licensing rL4ulrLoWlts a% I 1111 a FROM TO
i hlensed architect or a regi%kr J proftss on it Lnlnktr
aLlln Ili 111 I Ill%IIII.%% 512E of NU Or INSPECTOR S
_I g y 111(,%%II11111 LIp ILl1y (tiI.LIll1117n% EXISrINO WUG SLO All SIGNATURE
and PTUIL%won%(OJL 1 —_
Llc or Reg No 1)11, PRESENT USE OF BUILDING FINAL APPROVAL
I IOML OWNI R-81111 DI R UI I I \R \I ION NOW I XISII NG BUILDINBs
ON LOT AND USE
I hertb) Illirm Ili it 1 am L\Llnpl Iron, till (Onti ILtnl % 1111111
Law for lhl following re 1%on ISLcoon 7011 % Bu%utL%% old -
Professions (ode) No PARKING �/
SPACES PROVIDED
I a% ounar of Ilk prnikrli ud1 tit, IhL %%Tisk and IhL
At rut IML Is not ImendtJ or III IL I td 1111 sill (kL1 on 1114 PROPOSED USE OF BUILDING
Business Ind ProfLnsurn Codi.)
CONSTRUCTION LLNDING AGFN( 1
1 hertby at hon Ili 11 thtre is I corm I uL tion Ilndmt. Iuu¢I IDI
the pislool lnlx til the work Ior Muth this IntinO 1% %%u LLI
(Sec 1897 (IV ( y PROPOSED MAX OCC
lrndLrs Name )( APPLICANT(MANIA W
N
Lenders Add _ A RE 76 ITYT v
� 1 certify
I y Ihat h Ivl naJ this apphL mon m2 %t tit til It lilt
above Information Is wrnu I agate to Lonlply w till 111(till PERMIT FEE
ordinances and Slate laws rel long to building c nlsomoon uW
hereby aulhona represen(ati%cs o"Ans Count) to tnttl upon ISSUANCE FEE
the above-mentioned properl) for tion purpost%
1
1TOTAL FEE
Z22- 0
i /l ---
Si I RI \I R%I I OR I)t Pl ANAIORY I AN(IUAOI
i Signature or Perm.t,ee UnI.