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Home My Public Portal About4520 TEMPLE CITY BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION 76M444' CE 876(Z 80) MISCELLANEOUS APPLICATION t� 1 hereby affl� 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 certflitd copy thereof(Sec 3800 Lab C) Ar Policy No Company FOR APPLICANT TO FILL IN' BUILoiwc /lS1� woow¢as 77 CK ❑ Certified copy Is hereby furnished Bull.ADDRED INE e O T anAon /` &Via Lotwury �T SS .! / 1. ❑ Certified copy D Flied with the county budding Inspection NEAREST department LOCALITY T c— C tX GROSS Sr Date Applicant NEAREST DISTwicr ouP ry PE Roc acD^_Y GROSS Sr Ld Z[/ Aad COAST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL V COMPENSATION INSURANCE DESCRIPTION LOT NO 7 ELocK M.. .y I�„„w rv. PO/ (urtual BT.YE MAJOR SECOND LOCAL a NO OF OLDG. (This section need not be completed If the work Involved TRACT Now ON LOT USE zone SP ECTAL CONDITIONS O by the permit Is for one hundred dollars (5100) or less) USE of SIZE OF LOT EXISTING BLDG G� I certify that In the performance of the work for which this 1 0 permit Is Issued I shall not employ any person In any manner OWNER TJtG �{j /,s� ~ so as to become subject to the Workers Compensation Laws MwIL OCCUPANCY GROUP Jr�! , w Date Applicant L ADDweSS �po� f7L 7u 5A p /� f--I a U) NOTICE NOTICE TO APPLICANT If after cooking this Certificate of 1. Iry /�jry�P(,�t �� TEL OCCUPANT LOAD z Exemption you should become subject to the Workers Compensation provisions of the Labor Code you must forth APPL CATION FOR EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER US¢ eE Oev INSPECTIONKnowl E] deemed revoked ❑ ❑ Pa Spec Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices' ID I hereby affirm that I am IlLensed under provisions of Chapter SAFETY PE..IT Q (LIST ITEMS BELOW) NO Or EXITS 9 (commencing with Section 7000) of Division 3 of the Busi ness and Professions Code and my license Is In full force and PARKING effect SPACES ReO D Pwovin E° License Number Llc Class LIMITED TIME USE Contractor Date ..TC P.TK F1 II am exempt from the licensing requirements as I am a censed architect or S registered professional engineer SIZE OF NO w INaP¢eroS a acting In my professional capacity (Section 7051 Bus- EXISTING BLDG aro Ales SIGNATURE mess and Professions Code) G RESENT USE Or BUILDING FINAL APPROVAL Lie or Reg No Date— C- v` 3,1L /2D 2$ HOME OWNER BUILDER DECLARATION NO of Ex ISTING BUILDINGS ON LOT AND USE I hereby affirm that 1 am exempt from the Contractor s License Law for the following reason (Section 7031 5 Busl p (� r� ness and Professions Code) NO PARKING 21 1 a Y f1 NO PROVIDED ❑ 1, as owner of the property will do the work and the # S S S S 88 structure Is not Intended or offered for sale (Section 7044 Business and Professions Code) PROPOSED USE OP BUILDING S S S S S I CONSTRUCTION LENDING AGLNCY 1 hereby affirm that there is a construction lending agency 0916-81 for the performance of the work for which this permit Is issued (Sec 3097 Civ C) / T ...e''7D5✓ Lenders Name PRoFtrSED MAX OC. , Lender!Address ' PERMIT FEE I certify that I have read this application and state that the above Information a correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to budding construction, TOTALFEE and hereby authorize representatives of this County to enter :,%:Z he above ryQltl property for inspection purposes SEE REVERSE OR EXPLANATORY LANGUAGE 7 SI a of Per ties y / at A/ 1 W04XIRS COMPENSATION DECLARATION 78M444- ' CE 875 (11 84) MISCELLANEOUS APPLICATION {� s.,ereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Ll Instim, or a certificate of Workers Compensation Insurance,or a Certified copy thereof(Sec 3800,lab C) Policy No Company FOR APPLICANT TO FILL IN ABnuwoixei4520 TEMPLE CITY BLV. Certified copy Is hereby furnished RX wDDRES:4520 TEMPLE CITY BLV. LOULIrr TEMPLE CITY, CA 91780 Certified copy u filed with the county building inspection �ocw�ITr NEAREBT department XX TEMPLE CITY, CA 91780 cwoee R LOWER AZUSA Date Applicant NEAREST LOWER AZUSA Oily"ICT x0 awouP ec.T e[ef[o Sr CROff ST `'2•�D/f n 2 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Q 1T COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAr xwwrwr STATE Mwiow eEwno LOCAL xo (mwu.l x0 or BLDOS (Thu section need not be compfeted if the work Involved TRACT NOW ON LOT USE EONS erEciwL DITIONS by the permit is for one hundred dollen ($100) or less) USE or I certify that in the performance of the work for which thiseizE or far EXunnG SLOG permit s Issued, I shall not employ any person in any manse" orx[R of buildin SHELLY H. LO m as to become subject to the Workers Compensation Lawsss AIL OCCUPANCY GROUP a Date Applicant woo w--4510 N. 'IM4E CITY BLV. w NOTICE TO APPLICANT If, after making this Certificate of CITY TF 4U CT1Y NOL (B18)44201452 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 provisions or this permit shall be TRAILER USE ❑ GEOLOGY INer[cTION ❑ No Spec Knowl deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El 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 Bum NO or EXITS 1`I FEE ness and Professions Code,and my license s in full fora anix effect Name of burs inesa PwRNIxG ((ri SPACES RED o Y MOV Io[DLL License Number Lie Class IgA 1A I�EIOT'1�II U.S.A Ii�C. 9 LIMITED TIM Contractor Date DAYS D.T. I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE or Ro or , INS r[eron S acting in my professional capacity (Section 7051, Bu! EXISTING BLDG _W171` STowIEe 1 nG ruwE cress and Professions Code) APPROVAL Lie or Reg No Date PRESENT USE or BUILDING FINAL IMPORT EXPORT HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS /OG I hereby affirm that 1 am exempt from the Contractor's ow LOT AND USE j- License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) No PARKING El 1, as owner of thePe ro rt will do the work and the SPACES PROVIDED P structure is net intended or offered for ale (Section 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE or BUILDING I hereby affirm that there u a Construction lending agency for the performance of the work for which this permit IS Issued(Sec 3097,Cis, C) Lender s Name PROPOSED MAX OCC Lender s Address 1 Certify that I have read this application and state that the PERMIT FEE— above information is correct 1 agree to comply with all County ISSUANCE FE[ ordinances and State laws relating to building Construction, and hereby authorize represe at Ives of this County to enter TOTAL FEE 25.00 upon the above-mentio ed pr p ty for inspection purposes ]CLC 7{X4-25-95 SEE REVERSE FOR EXPLANATORY LANGUAGE Sigmiture of Perimtiee IDTte WORILRS (ONIVI MAHON UI I I \R VION nLXll nPtn ,,,, MISCa LLANtUti15 AeeLIC.AI IUN • I ITC10% aflom (hat I h ltL I LLIl111LJiL nl LnII,LIII Jl ,.h COUN I Y OF I OS ANIGH fS BUILDING AND SAI-M' DIVISION r II I Insure Or a LenJICIUL til Wor{An (om PLMlulm I1I,01 LILL or I certified Lop) Iheretil (SLL 3M) 1 Ih ( I PoIny No Collip til) FOR APPLICANT TO FILL IN AOGp[69 \ 8 BUILDING ADDRESS (endleJ Lop) n htrL h} lunn>htd dof'S •)QM LOCALITY Certified copy P Idtd VIII) Ills Lounl) bu11Jmi, ill IKttion CITY + ZIP p� -1 deparlmult liYlr i g/ 7CROSSST Date _ \ppllL IIII 512E OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY CONST (t RIII I( All UI 1 XLMPIIUN I ROM XNURAI I(1 TRACT BLOCK LOT NO (ONIPLNSAIION INSURANl 1 •+� •�ca.+• t NOY ic.CLLI STATE MAJOR SECOND LOCAL (This ,tllion nted not be Lonaplltd 11 IIIL NIIIL 111 (llttd ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS r III) IhL Perna Is Gtr BILL hnndrad dollar, Is 1101 oI ILx) t.i TEL NO — I ttrul} II)II m Ihm mi l rxrltilt III Ihl ewA III ehllh IOWNERhl, _ I 1 pLrmu IS 1»uLd I $11.111 not tmpllq In) IL11M,n III u1) nlannLr so as to become ,ubJLLI it, IhL Illi to (umlx n,man I IN, ADDRESS OCCUPANCY GROUP , Dale_ _ APpht Jni VITT ZIP NOTICL TO APPLICANT It dill In Ik Ing IIII, ILrlda lie OCCUPANT LOAD of Lxemption sou should become ,ubletl Io II), N uk,h APPLICATION FOR EXIT HARDWARE Compensation pro,isaon,til the Labor(tidL )ou ILIUM lorilm nh COmpl) With ,IILtl prUtHWM or 1111, rkrinin till hl tilllllt.d TRAILER Uyt❑ GEULOGY INSPECTION NO SpecI(f10W1 ❑ revoke) OCCUPANCY INSPECTIONK Panic Devices ❑ ' LIC LNtiLU Cl1NIRAC IURS DI( I AR MON I hereby aft lrm that 1 IIII ItLlnsed undLr pnn kions of (111pLr SAFETYPERMIT❑ LIST ITEMS BELOWP J 9(commencing u till SLOim 70000 of Do kion 1 of II), Business NO OR EXITSEj and Professions(odt, and m) Tiede Is in lull lora old LfILLI 1, p C]A I`l( L" L.,11L I11�S� PARKING RED D PROVIDED l ICenu NlllllhLl I n ( I I,s x ��— SPACES G� LIMITED TIME USE 1 I Colli IL IUr PILL DATE DATE ] ❑ I and a\emp1 Irom the 111LIhI11E rt Lhllltllhlll, a, I an J FROM TO bten,ed architect or a regl,ILrLd prof�%slan J LnpmLLr r acting in nl) prolt„fund LIPIuq (ltlbou 7(1,111u,mts, SIZr OF Noor INSPECTORS �• ,�) EXIbrIN1.1 IG STORMS SIGNATURE and Prolt„Ions (odl) Lie or Reg Nu O TIL PRESENT USE OF BUILDING FINAL APPROVAL I — I _ 7v _�JcL� rr 11(1X11 OW NI R-81111 UI R DI l l \R \I ION Nu or LAn nNc euaDlracb UN LOT AND USE htrth) Ill not III II I till L\Lmpl hom (hL (onll Klnl s I I,LoI law for thl Iolhtmulg rta,on tSL,.Iion 11111 , Ila,uns Ind Professions (tide) NO PARKING ❑ 1 ds 0Mnlr til Iht pinlxm Dill JP Ihtwd III. NJ SPACES PROVIDED _ IL ,I rutuUt I, not m1entiLd ui oI IIIL) Int ,JL (111111111 1014 PROroSCU USE OF BUILDING Busme„ and Proll,mon, (lid,) I (ONSI RIX IION I I NDI NO Ald N( 1 lwrtb) III Irm til It IhLrL 1, I t0II%Il IIL11011 ILtIJIIIL aunt IBI the rllrtorm oat til thl WotA Tor xhlth Ilu, Ixuml I, "'LI'd ($et 1(197 (IV I. I PROPOSEDMAX CC LendLrs Name _ APPLICANT(00,r1AR� I Lenders AJJrt» woo cp ss l ! � t� cendy Thai I have mad Ihu apphtaulKl and It ILL II)It till RWm7 cog epk above Inforination Is torRll f agrte totompl) oilh all(011111) PERMIT FEE I ordinances and Stale laws TO ding to budding ton,Innll In u1d hereby authorize repre,enlatlt Ls of this (oUllt) II) Ln Itl Upon ISSUANCE FEE the above-mentioned proper) for or' urn put plus TOTAL FEL J I 0 ^ S1 I RI VLRSL [OR ULPI ANATORY l AN(&A61 — nature of Permmu Dal,