HomeMy Public PortalAbout4805 TEMPLE CITY BLVD_Miscellaneous__ • WORKERS'COMPENSATIONDECLARATION
CE 876 11184)44 MISCELLANEOUS APPLICATION {1
CE LJ
1 mom,
o affirm cert that 1 have a s Come of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, qr a certificate of Workers Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BmLoDR¢BBrrvG 6D�-
wDJ
Q Certified Copy is hereby furnished BUILDING
4 4Z
ADDRESS 4805 TEMPLE
LOCALITY _
ElCertified Copy is filed with the county budding inspection LOCALITY neva Ear
department TEMPLE esu o¢a ST
Date Applicant Ne ARBST �ryry�'�rC�,,pr, DISTRI T NO O oUE rYe¢ Ce¢5¢D er
c11 o¢O ST LJD r' ,rn O r _ �] CON¢r
CERTIFICATE OF EXEMPTION FROM WORKERS' LaGwL O Os
COMPENSATION INSURANCE D¢9CR IPTION LOT No BLocK MAP w%CLi) STATE MAJOR SECOND LOCAL
(Thu section need not be completed if the work involved No Or RLDoa A
p TRACT Now or Lor ], u¢Q zon¢ areeuL CONDITIONS
by the permit is for one hundred dollars 1$100) or less)
uaE DF
I certifythat in the ¢¢e OF Lor UK X, IND BLDG
performance of the work for which this 1 11
permit is issued, 1 shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws
_ MAIL OCCUPANCY GROUP 6lOs o
Date Applicant ADDRES W
NOTICE TO APPLICANT If, after making thus Certificate of CITY'S No 1 OCCUPANT LOAD D_
Exemption, you should become subject to the Workers' 19
Compensation provisions of the Labor Code,you must forth- P KATION FOR /lbs" EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USE
deemed revoked P
o¢oLoot INSPECTION Spec Knowl
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT (LIST IT¢MS BLOW)
9 (Commencing with Section 7000) of Division 3 of the Busy No OF BAITS
ness and Professions Code, and my license u in full force and
effect f.,e - PA RKIRB
SPp CBB RQOO D PROVIDED D
License Number Lic Class LIMITED TIME USE
Contractor Date DwTa DwT.
DI am exempt from the licensing-requirements as 1 am a P,.oM To
licensed architect or a registered professional engineer slzQ of ND or - Tow a
acting m my professional capacity (Section 7051, Bus- QAISrINo BLDo 915 E.Q. ft. STORIMS 1 SIGN Re
mess and Professions Code) RESTAURANT FINAL APPROVAL PRESENT VS¢ OF BUILDING 7Q
Lic or Reg No Date 19't
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS rE]C• 1 'CI :CIY
ON LOT AND am 1 GI�
I hereby affirm that I am exempt from the Contractor s �
License Law for the following reason (Section 7031 5, Busy '
ness and Professions Code) NO PARKING
❑ 1, as owner of thePe ro rt will do the work and the SPA.MS PRov ID¢D ✓��
P
structure is o not intended or offered for We (Section _
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED VSB OF BUILDING RESTAURANT _
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 Bee
Lender's Address
1 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 budding construction, Oa
and hereby authorize representatives of this County to enter TOTAL FEE
upon the ve mentioned property for ms ec on purposes
SEE REVERSE FOR•EXPLANATORY LANGUAGE
Signatur of Permittee Date
I I
WORKERS COMPENSATION DECLARATION
CE 875 l2 801 MISCELLANEOUS APPLICATION
CE 876
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)
Policy No Company FOR APPLICANT TO FILL IN wooecae
❑ Certified copy is hereby furnished BUILDING 91114 -}' LOCALITY
Certified copy Is filed with the county bmldmg mspecton �e NEA RE
department LOCALITY CA r CROSS ST O.wL(/(i
Date Applicant NEARS ST DISTRICT N o OUP rY PH PRoc Serer
.CROSS'BT '� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL Y
COMPENSATION INSURANCE DESCRIPTION LOT No eLOcx11
.NjuRUSI STATE MAJOR SECOND LOCAL >_(This section need not be completed if the work involved TRACT NrvO OF oLDOS Q.
ow ON LOT USE ZONE SPECIAL CONDITIONS O
by the permit Is for one hundred dollars (S 100) or less) use or U
1 certifythat In the SIZE OF LOT HxISTING RLDO G/
performance of the work for which this 1 ' ¢¢
permit u Issued I shall not employ any person to any manner OWNERCompensationV N U
so as to become subject to the Workers Compensation Laws AIL OCCUPANCY GROUP ��
ADDRESS W
Date Applicant d
//..
N
NOTICE TO APPLICANT if after making this CertiflCetL Of CITY { 1.�� wo I OCCUPANT LOAD Z
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 INSPECTIONNO $ BC KnOWI ❑
deemed revoked P
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 0 Panic Devices ❑
1 hereby affirm that I am licensed under provisions of ChaptLr SAFETY PERMIT q (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of the Bust
nms and Professions Code and my license Is in full force and PwRxINa
effect
SPADES RHO D PRoviDeD
License Number Lie Class
LIMITED TIME USE
Contractor Date DwTS DwTS
F11 am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineLr sae OFINSPECTOR a
acting in my professional capacity (Section 7051 Bus EXISTING BLDG "o OrS eiarvwruwe
No o•
mess and Professions Code) 11 RHIHFINAL APPROVALNT USE 0I BUILDING
Lie or Reg No Dale
HOME OWNER BUILDER DECLARATION NO o Ex18T1 O BUILDINGS
'NO
LOT AND USE
I hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 7031 5 Bust
nese and Professions Code) NO PARKING
SPACES PROVIDED
❑ I, as owner of the property will the work and the 0 8 Z 0 A
structure is not intended or offered for sale (Section -
7044 Business and Professions Code) 00 ROPOSHD USE OF BUILDING # • • • • 88
CONSTRUCTIgN LENDING AGENCY I ( �/'i • • •4 S A S
I hereby affirm that there is a construction lending agenLl �-!
for the performance of the work for which this permit Is g 1 9-81
issued (Sec 3097 Cly C)
Lenders Name
PRovoseD MAX occ
Lender's Address PERMIT PEE
1 certify that 1 have read this application and state that on
above Information Is correct I agree to comply sslth all County ISSUANCE FEE �,.„
ordinances and State laws relating to building my to erste TOTAL FEE 5 OD �/G�(//
and hereby authonze re sentetves of this County to enter
OA. the above mention property for inspect purposes E REVERSE [OR CXPLANATO Y LANGUAGE
/ r
ore of rmI Date
WORKERS COMPENSATION DECLARATION
CE 875(2 BO) MISCELLANEOUS APPLICATION {�
CE 876 LJ
Tint erefe of 9 certificate of Workers 4rthat I have a eCompensation Insurancertificate of consent to self or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
e certified copy thereof(Sec 3800, Lab C)
Policy No Compan) FOR APPLICANT TO FILL IN BUILDING O TP'ru
[Z C(Tr B L
ADDR¢e{
❑ Certified copy is hereby furnished uuOl Nc
Q-' 7� Ll- C(rr LOCALITY
❑ d
ADDR688
Certified s filed led with the county building inspection NEAREST
department LOCALITY Q/ �Z C/Tr
cwoae aT /-owab Aziir4 go
Date Applicant RASESr /_ DISTRICT a ouP TYPE PROs s¢D BY
CROS{ 8T IDW 2aS I c ONYT
CERTII KATE OFI EXEMPTION FROM WORKERS' LEGAL J'
COMPENSATION INSURANCE DESCRIPTION LOT(No 'Loc. MAP ",onwA }
no of eLDas
_ (ciwcc.l STATE MAJOR t¢ NO LOCAL a
(Thu sec[ron need not be completed If the work involved ' TRACT NOiS ON Lor USE zone SPEUAL comm�owa U
by the permit is for one hundred dollars ($100) or lea)
USE TI ��
SEE oP LOT cxiannc BLDG
1 certify that m the performance of the work for which this
permit u Issued I shall not employ any person in any manner nwE 6cl;r,C 7/ff71-1- F&222 /9V C '
so as to become subject to the Workers Compensation Laws M IL 7L/ 3 R&4 RD s'liftf 3 OCCUPANCY GROUP W
Dwwae
Date Applicant A
1 NOTICE TO APPLICANT If after making this Certificate of v Y1/�(L/V1L4T nK.L(7f OV-00fil OCCUPANT LOAD z
t 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 TRAILER USKO GEOLOGY INSPECTION
deemed revoked Ell NO Spec KnOWI El
LICENSED CONTRACTORS DECLARATION DCCUPANC.us.P¢CnoN Panic Devices ❑
1 hereby affirm that I am IKsnsed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of the Bum
El
ness and Professions Code and my license is in full force and PARKING
effect SPACES RE D Pw oviocD
License Number Lm Class
LIMITED TIME USE
Contractor Date AT. R.T.
❑ I am exempt from the licensing requirements as 1 am a PROM TO
I censed architect or a registered professional engineer SIZE owno OF INSPECTOR a
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG .TORIES JIGNAYURE,
mess and Professions Code) cnT USE OF BUILDING FINAL APPROVAL
Lac or Reg No Date
HOMEOWNER BUILDER DECLARATION ONO OF EXISTING BUILDi aS
n LOT AND USE
I hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 7031 5 Busi 8 2 2 7 6 A
ness and Professions Code) NO PARKING
❑ roSPACE{ PROvao¢D # * 00 , 88 S S S 8 D
O
I as owner of the property will do the work and the
structure is not intended or offered for sale (Section *d t d a S
7044 Business and Professions Code U
oleo use OF BUILDING
IR
CONSTRUCTION LLNDING AGENCY AAq�
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 )
Lenders Name PROPOSED MAX Oce
Lender s Address PERMIT FEE
1 certify that I have read this application and state that the ,
above information s correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to budding construction TOTAL FEE '
and hereby authorize representatives of this County to enter
u the abov<mentioned property for inspectio; purpose SLF REVERSE I OR EXPLANATORY LANGUAGE
-- Hal S91 N I�I�N�
Signature of Permit[ :a Date
,WORKERS COMPENSATION DECLARATION 76M444
CE 876(280) MISCELLANEOUS APPLICATION
I hereby 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
i` a ce lified copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN eUILO1N0 n
Certified copy Is hereby furnished Bu uOlna
wooweSS Loewurr
❑ Certified copy Is filed with the county budding Inspection f NEAREST
department LOCALITY GROSS ST a�yv
Date ApplicantwAREST DISTRICT n ou• TYPE Pwoe Se+�7`-
OSS ST C /S 1� SONNY
BY
CERTIFICATE Or EXEMPTION FROM WORKERS LEGAL r v
COMPENSATION INSURANCE DESCRIPT,on Lor NO ,;3 BLOCX w.. .� /e� Ia,.v,wv }
no ow ei.OaS
_ No " IcucL.l STATE MAJOR SECOND LOCAL a
(This section need not be completed If the work involved TRACT Now Or LOT USE zon¢ aP EaIAL CONDITIONS O
by the permit u for one hundred doBgrs (SI00) or leas) USE o. CMZ ¢
SIZE OF LOT eR 1ETING BLDG
I certify that in the performance of the work for which this O
perms[ is Issued, I shell not employ any person ,n any manner OWNER
j tY_Jf" U
OCCUPANCY GROUP
so as to become subject to the Workers' Compensation Laws AIL ��— W
ADDRESS , 11
Date Applicant rn
NOTICE TO APPLICANT If after making this Certificate of I 7A02
TEL 1 OCCUPANT LOAD z
Exemption you should become subject to the Workers A KATION 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❑ No Spec Knowl ❑
deemed revoked
LICENSED CONTRACTORS DECLARATION occuvwrvcr IrveP¢cnoN� Panic Devices ❑
1 hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busl
ness and Professions Code and my license Is in full force and
effect PARXIrvG
REG D PRovloeD
SPACES
License Number LIc Class
LIMITED TIME USE
Contractor Date D.T. D.TS
❑ I am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer SIZE of No oP INSPECTOR S
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG pTOR,Ea SIGNATURE
mess and Professions Code) BS¢NT USE OF BUILDING FINAL APPROVAL
Lic or Reg No Date
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 7031 5 Bus, 41 a 6 A
ness and Professions Code) No PARKING
❑ I as owner of the property will do the work andSPACES PROVIDED'the # Is
•'• a
structure Is not Intended or offered for sale (Section
7044, Business and Professions Code) PROPOSED uS¢ of BUILDING
CONSTRUCTION LENDING AGENCY 16 —B Z
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)
Lenders Name PROPOSED MAX Dec
Lender s Address PERMIT FEE
I certify that I have read this application and state that the ISSUANCE FEE
above Information Is correct I agree to comply with all County ,
ordinances and State laws relating to budding construction TOTAL FEE 25.00 (Pay to City of Temple City)
aV hereby authorize representatives of this County to enter
on [h above mention d property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of P<rmrttee D' D to
WORKERS COMPENSATION DFCLARATION 76M444
CE 875 (2 80) MISCELLANEOUS APPLICATION
i hereby affirm that 1 have certificate of consent to self
inj sure or o certificate of Workers
COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISIONrs Compensatioh Insurance or ,
a certified copy thereof(Sec 3800 Lab C )
Polley No Compan) FOR APPLICANT TO FILL IN BUIDRESSLDIrvG
- AD
❑ Certified copy is hereby furnished L,
wooee E9 V� LI✓� LOC.LI7r
❑ Certified copy Is filed with the county building inspection ......T
,department LOCALITY CROSS ST
Date ApplicantEAaf9T DISTRIeT No enouP TYrE Ro neap BY
CROS
9T alaw O� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LCGAL
COMPENSATION INSURANCL DESCRIPTION I LOT No Eto.. m�ww
"A"Z (sins Lel STATE MAJOR SECOND LOCAL d
(This section need not he completed If the work Involved No oP BLDOE
by me permlt IS for one hundred dollars (.SIQD) Or less) TRACT NOW ON LOT U8Q ZONG EP CCIAL CO NOITIONB L)
USE OF I TI
I certifythat in the eizE of LOT ExIErING eLDe �, 0
performance of the work for which this 0
permit Is Issued I shall not employ anv person in any manner WNEW l'—
so
so as to become subject to the Workers Compensation Laws AIL ^' OCCUPANCY GROUP _� w
ADDRESS Y7All PP
a
Uata Applicant N
NOTICE TO APPLICANT If after making this Certificate of uTr NO
Z
Exemption you should become subject to the Workers L6 O/T —/ OCCUPANT LOAD
Compensation provisions of the Labor Code you must forth APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION
deemed revoked ❑ ❑ NO Spec Know) ❑
LICENSED CONTRACTORS DECLARATION
occurwrvcY iNsrixcrloN Panic Devices ❑
1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO OP EXITS
9 (commencing with Section 7000) of Drsision 3 of the Busl
ness and Professions Code and my license Is In full force and
effect PARKING
A SPACES REO D D PROVIDE.
rrL��i__cense Number LIc Class — LIMITED TIME USE
pntractor Date I AT. AT.
1❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OFO or INSPECTOR S
N
acting in my professional capacity (Section 7051 Bus EXISTING BLDG :TOROSE SIGNATURE
(ness and Professions Code)
QeENr uee OF eulLOlrvG FINAL APPROVAL Oz
Loc or Keg No Date ! fD Q r
G I I
NO OF EX.STI.Q QUILDINGB • • •
HOME OWNER BUILDER DECLARATION ON LOT AND use
1 hereby affirm that 1 am exempt from the Contractors 0105-8 J
License Law for the following reason (Section 7031 5 Bust
ness and Professions Code) NO PARKING
SPA 95 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) PWI5POSED DEE OF BUILDING _
CONSTRUCTION LENDING AGLNCY C '
1 hereby affirm that there Is a construction lending agency A 'oFaif" AJ
for the performance of the work for shish this permit Is
issued(Sec 3097 Civ C)
Lender s Name
i PROPOSED MAX OCC
Lender s Address
PERMIT FEE '
I certify that 1 have read this application and state that the
above information rs 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 Counts to enter
upon t// pro//pJJerty (L�
the above mentioned for inspection purposesSEF REVLRSL 1 OR EXPLANATORY LANGUAGE
Signature of Permittee Date
WORKERS'COMPENSATIONDECLARATION 76M444 MISCELLANEOUS APPLICATION
CE 875 (11 84)
insure hereby
a�certificirm ate of Workert I have a s'Compensation Inertificate of suurancce self
COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION '
a certif'ted'copy thereof(Sec 3800,Lab C) C"'
Policy No Company FOR APPLICANT TO FILL IN aulLol95
w DORaES V
FiCertified copy Is hereby furnished BUILDING LOCALITY.
wDDRESs
❑ Cert�ed copy is tiled with the county building inspectso 905 TeMYLE GTT 6L (1 N¢AR¢CT
LOCALITY
department caoeS Sr � v
Date Applicant NaARHer I ` MCT No GROUP Tyre oc¢e ¢y.eY
Crt088 8T WU ZU S CONIY `J
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO BLOCK MOP !co^OwL�.
STATE MAJD SKCOND LOCAL
/7t NO OF SLOGS\Susi sperm Seed not be completed If the work or less) TRACT NOW ON LOT Uy¢ zONE SPECIAL CONDITIONS
by the permit to for one hundred doBers (5100) or less) ILS¢ of --.0 /I
SIZE OF LOT ¢x%TINO ISLD0 1 J
I artdy that to the performance of the work for which this I (Ol��
permit u issued, I shall not employ any person in any manner
tj
so as to become subject to the Workers' Compensation Laws MAILER OCCUPANCY GROUP
ADD.a's
Daft Applicant v.+
NOTICE TO APPLICANT [f, after making this Certificate of' clTr li TOL ?$6— OCCUPANT LOAD o_
Exemption, you should become subject to the Workers'
Compensation provinoms of the Labor Code, you must forth APPLIC TION FOR EXIT HARDWARE
with Comply with such provtsions or this permit shall be TRAILER UEC: ❑
GEOLOGYdeemed revoked IN¢PH cr1oN No Spec Knowl ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI (LIST ITEMS SLOW)
9 (commencing with Section 7000) of Division 3 of the Busy NO of EXITS
ness and Professions Code,and my license is in full force and
effect J)NW OF PARKING
SPACES R8q D D FROVIDiO (�
License Number Lic Class 'ETC ��2.
Contractor Date &M r Cr LIMITED TIME USE
DAT• SATE
PROM
I am exempt from the licensing requirements as I am a
To
licensed architect or a registered professional engineer else OF NO OF INCPE Crow S
acting in my professional capacity (Section 7051, Bus- %ISTING BLDG STORIES SIGNATURE
mese and Professions Code) D �'CC FINAL APPROVAL (- (y
Lic or Reg No Date PRKSKNr USE OF BUILDING / V
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDING
oN LOT AND UBE N0 r
I hereby affirm that I am exempt From the Contractor's _ lJJ G
License Law for the following reason (Section 7031 5, Busi-
ness and Professions Code) No PARKING /�
SPACES PROVIDED I I OOpO-0001 10/ �7 V9
1, as owner of the property, will do the work and the I
structure Is not intended or offered for sale (Section I r N' (,�' 6072 1 AM 9;,44
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROP.CED USE OF BUILo 1NG
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is O f a 1 1
Issued(See 3097,Civ C)
Lender s Name
PROPOSED MAX OCC \ \
Lender's Address
I certify that 1 have read this application and sinPERMIT FEE
e that the ,
above information is correct 1 agree to Comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, O ,
and hereby authorize representatives of this County to enter TOTAL FEE
the above-mentioned property for inspection purposes
\ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
HORKLRS COMPENSATION DECLARATION 78M444-
1_� CE 875(1184) MISCELLANEOUS APPLICATION
I hereby.tient that 1 have a certificate df convent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Worker s'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN .u1LOIno
woow[SS I�.pw E, _ C I�
Certified copy is hereby furnished RX .Bnow ILOstn:U .. 4 2 OS Te fN LOCALITY
Certified copy I filed with the county budding inspection LOCALITY NEww[ST
department XX ewoLO rnCA Sik
Date Applicant 2 LA O _�
NewCoeA.e ESrSr LJ412 ler No .our TTP- c[eSED Er
18. cDNS
r
CERTII KATE OF EXEMPTION FROM WORKERS' LEGAL eI
COMPENSATION INSURANCE DESCRIPTION Lor.o BLOC. Mo• ;cw^��� .TATE wwiow e[cono LOCAL
LD6a
(This section need not 6e Completed if the work involved TRACT
Or B
ed rwwcr rvor on Lor uS[ :onE Sr[e.wt eono.rwNS
by the permit is for one hundred dollars ($I00) or less.) USE or
[...TING SLOG
1 certify that m e.zE or Lor the performance of the work for which this o
permit Is issued, 1 shall not employ any person in any mane Gw.a. of buildin S
so a1 to become subject to the Workers' Compensation Laws MAIL wD....S I OCCUPANCY GROUP B-a
Date Applicant AM
NOTICE TO APPLICANT If, after making this Certificate of elrr 12ad2a .Bice t ( OCCUPANT LOAD z
Exemption, you should become subject to the Workers' —
Compensation provisions of the Labor Code,you must forth APPLICATION FOR EXIT HARDWARE F
with comply with such provisions or this permit shall be TRAILER US[ n[OLOGr INSPECTION 0 No Spec Knowl Ii 1 ��
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANcr INSPECTION ❑ Panic Devices _ •I_,_Ifif11 - -
'.e
I hereby affirm that I am licensed under provisions of Chapter
Swr[Tr PERMIT (tiITEMS[Ma auoi)
9 (commennrlg with Section 7000) of Division 3 of the Busy NO Or EXITS�
Tress and Professions Code,and my license is in full force an
effect I Name of business PARKING
SPACES .too � rwov mco
License Number Lie Class i'
LIMITED TIME USE
Contractor Date DATA RATS
El1 am exempt from the licensing requirements as I am a •.o. TD
licensed architect or a registered professional engineer SIZE or No or INSPECTOR S
acting in my professional capacity (Section 7051, Bus- FASTING BLOC SroPIES uG URE
mess and Professions Code) PRESENT USE or BUILDING FINAL APPROVAL r� `
Lie or Reg No Date
HOME OWNER-BUILDER DECLARATION no or SX STING BUILDINGS O ��
ow Lor AND tie[
I hereby affirm that 1 am exempt from the Contractor's t�
License Law for the following reason (Section 7031 5, Busr
ness and Professions Code) NO PARING
1, as owner of the property, will do the work and the SPACE. PROV.O[O
structure is not intended or offered for sale (Section f
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY Pw OPO[EO USE or BUILDING
I Hereby affum 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
I certify that 1 have read this application and stale that the PERMIT FEE
above Information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State taws relating to building construction,
1 and hereby authorize representatives of this County to enter TOTAL FEE 25.001
upon the above-mentioned property for inspection purposes
1 8£E REVERSE FOR EXPLANATORY LANGUAGE
XX g 6 / , xx 02-22 - 9S
Si patiof Pernuttc Drte
WIJKACKJ LVMFLI`IDAIIVry UtILAKAIIVry
>a1 2000sOPW11 .„� MISGtLLAMtVVS iarr�.I�.HI �LJIY
I h �alT rte that 1 have certificate of consent self COUNTY OF LOS ANGELES WILDING AND SAFETY DIVISION
msdfe.or a certificate of Workers Compensation Insurance or
a certified copy thereof (Sec 3800 Lab C)
Policy No. _ Company __ FOR APPLICANT TO FILL N. euILOINc Gtr
H
BUIL Ol �1DBE3$ `j ADDRESS D �J tet_ "L�
Certified copy Is hereby furnished
Certified copy ns I Iled with the county building inspeLtion CITY/ ZIP LOCALITY �-
departmentL / NGRLST
CROSS ST
Dalt Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT DiaTR �NOf 2rP TYPE CESSED BY
OV 4
CERTIFICATE OF EXEMPTION FROM WORKERS CD ST TRACT BLOCK LOT No _
COMPENSATION INSURANCE
vA
(This Section need not be completed If the wort( Involved ASSESSOR MAP BOOK PAGE PARCEL w 1 iCO'4ei STATE MAJOR SECOND LOCAL
by the per ul 1$ for ogle hundred dollars (5100) Or ICsS) W, UMEZOVE SPECIAL CONDITIONS
I certify that in the performanLe of the work for which this i OWNER ` TEL NO
permit is Issued, I shall not employ any person In any manner Pro eit j,(a S1Sjp
SO as to become subject to the Workers Compensation Laws I ADDRESS
Z 6 t% T OCCUPANCY GROUP
Date Applicant CITY gg Zip
NOTICE TO APPLICANT If after making this Certdicate Lt SCt R Y C C%
of Exemption you should become subject to the Workers OCCUPANT LOAD
Compensation provisions of the Labor Code you most forthwith APPLICATION FOR E OT HARDWARE
comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑
revoked No Spec Known
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter SAIETY PERMIT❑ (LIST IT[Ma BELOWi
9(commencing with Section 7000)of Dn Ision 3 of the Business NO OF EXITS
and Professions Code and my licen.e is In full force and effect /I'LL )2 C,-,
License Number LIL Classr �f� SPACES
RED D PROVIDED
-C LSC JLcC J
Contractor Date 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
acting in my professwnal capacit (Section 7051 Business SIZE of ND of INSPECTOR a
and Professions Code) exlsrlNC BLDG STORIES SIGNATURE
Lic or Reg No Date PRESENT Use OF BUILDING FINAL APPROVAL7,7
/C,cfj C
b O �1
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS
ON LOT AND USE I
' I hereby affirm that I am exempt from the s License
Lar for the following reason (Slltion 7031031 5 5 Business and 0
' Professions Code) No PARKING �SPACES PROVIDED
I as owner of the propert} well do the work and thq�
structure is not Intended or offered for sale(Section 74X -ROPOSED USE OF BUILDING
Business and Professions Code)
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
(See 3097 Civ C) PROPOSED MAX OCG
Lenders Name APPLICANT(R T) TEL NO
Lender s Address ADOREae
I certify that 1 have read this application and state that the
above information is correct. I agree to comply with all County PERMIT FEE
ordinances and State laws relating to budding construction and
hereby authorize representatives of this County to enter upon a FEE
the above-mentioned property for inspection purposes
Q -DTAL IEE
�7 i
t - D SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
110RAI ILS (OAIPI NS.\IION UI( LARAfION
CE 876 111 841 MISCELLANEOUS APPLICATION J'1
CE 876 L, I
".retry affnm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION IILJII
mare or a certificate of Workers (ompenallon Insurance,or
I certified copy thereof ISeL 3800 Lab C)
PNh(y No _ — (ompnny — FOR APPLICANT TO FILL IN BO ILOIN6 ����
woowus
FICertiflLd Lop) Is hereby furnished culLn m° Lou urn /
XX woowEs•
ElCertlDed wpy is bled%%tlh the county budding Inspection LOCALITY NEAREST
department 31;$ ew Dff ST
])ale Appinant—_ eneAe•T DISTRICT No ;Fop IT cEfuD Br
ewofs ST G Q eoNfry�
(I R I II I(All 01 EXEMPTION 1 ROM WORKERS LEGAL 1�
(ONIPI NSA nON INSURAN(1 DESCRIPTION LOT NO BLOCK MAP ...NA•
ICIn<Lll STATE MwlOw •{GONG LOCAL
NO OF BLOBS
(Flit, section need not be completed if the work Involved TRACT nee ON LOT USK :owe •PEcuL Co wo monS
by lite permit Is for one hundred dollars (11100) or less) use or
SIZE OF LOT BXIfTING eLo
I LertifyI tint d, the performanLC employ
of the work for any
ichma this
pcnnu n Ica"ed, I shill not employ any person In any rrunneRX ow New of building
1
v. is to hctome sulgrU to the Rotker% (ompenution I Tus OCCUPANCY GROUP °i
wwu
woowe•s
Date — __ ApphL Int
NOIR I 10 APPLK ANI If after nuking this Certificate of CITY NO I. OCCUPANT LOAD >>
I xemption, )ou should become subject to the Workers APPLICATION FOR EXIT HARDWARE
(ompenation ptovwons of the labor Code you must fork O
with Lompl) Ruh mit prO%t%anns or tilts permit shall be TRAILER USE ❑ OeOLOOV INSPECTION ❑ filo Spec KnoWl
deemed te%oked
I R 1 NSI 1)(ON 1 RACIORS DECLARATION OCCUPANCY INSrecTlon 11Panic Devices
I herch) affirm Ihil 1 am licensed under provisionsof luipler SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (anemenLing with Section 7000) of Dwisson 3 of the Bun- wo o. EXITS
nes% and Professtona(ode and m) licence Is in full fora anix Name of business
effeLt n PAwNIND weo o --tit-
V S, KS
I at.nsL Number I IL (lass
LIMITED TIME USE
l onfr U Nr _ _ —__ _ — Date _— 0 DATE ^"'•
El1 Tm exempt from the licensing requtremenls as 1 am a
I tensed anhlle" or a registered professional engineer SIZE or NO OF I:SPEW oR
2d Ing to my professional Lapactty (Section 7051 Bus EXISTING BLDG STORIES
messand Profe%slons(ode) FINAL APPROVAL
PRESENT use e1 BurLOrn6 1� 10
1 "c nr RLg No - _ _ _ _ ---- Dale /,{ �(�
IIONII OWN[ R 131111 DFR DI CLARAIION No of EXISTING BUILDINGS (%e
ON Lor Ano ufe (' �'JF MCI
I heteb) nftunl that I Ito exempt from the Contractors
1 ILenw I aw for Ilse lollN%%Ing retain (Seddon 7031 5 Bus,
nes% and Professions(Niel No PARKING
I, a% owner of (lierN eel will do the work and the SPACef PROVIDED
structure not upended or offered for sale (Section ¢i� (�pll t
1
a tr
7044 Rusme%s and Professions(ode)
(ONS I RLICI ION I LNDING AGLNCY PROPOSED USE or Bull-DING
I hereb% affirm that thtre is T Construction lending agency bc NUTSge
for the perfonnmLC of the work for whlLh this permit Is
Issued(Sec 3097 (w ( I
I ender s Name
PRDPOSeD MAi-OCC
I Coit."s Addtc<s___ _ __ _— —_ — i
I certify Ilut I hnr rt.ad 1111% dpphL loon coif state Ilial the PERMIT FE!
IbO%L InfNrlll"tion I%Lorrc0 I "Fret. In Lomp1) wllli all(Ounty ISSUANCE FEE
ordinance% Ind Stale tau% rLlating to building construdion,
' and hereby aulhorve representatwes of this County to enter TOTAL FEE 25.00
upon the i1Xne mentioned property for mspLLtion purpose%
/ SFF REVERSE FOR EXPLANATORY LANGUAGE
XX XX / XAW
I h n.