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Home My Public Portal About4816 TEMPLE CITY BLVD_Miscellaneous__ i WORKERS COMPENSATION DECLARATION 375 (1t B41 MISCELLANEOUS APPLICATION n CE CE 1 I hcmbv affirm ^at I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION instate Gr a certilicrte of Workers Compensation Insurance or �. a certified Lop} therea (Sec 3800 Lab C) Policy No Company FOR APPLICANT TO FI LL IN eu uO roc '75� AOORH99 Certified copy Is hereby furnished rte ew esu \ J Lo cw urn 1 I Certified copy is filed with the county budding inspeLtnon Locwurr TNEAR. department emple City CR033 3T Date Apphc tit NEAR GBT Lr �I'/ Z 'IsTFICT NO OR P TYPE e33[O RY CR09f 9T 1 QfaV CONST CERTIFICATE OF E\EMPTIO\ FROM WORKERS LCGAL i COMPENSATION I\SLRANCE OHsc RrPTION LOT No BLOCK IMA. .a Nw A. Na �CIn LLf) STATE MAJOR SECOND LOCAL (Thu section need not be completed of the work involved I No of HLoas 'RAL' 1041 ON LOT ZONH 9Pf C1AL CONDITIONS by the permit is for one hundred dollars (S 100) or less) •3G of l 131ZG OP LOT C%13TING HLOa 1 certify that in .he oe• ormance tit ,he work or which his I = permit is issued I shall iot emplos ani person n am nanne• owNeR Che _ L C) -' m as to become sublet• o the l\0rkers Compensation Lasss OCCUPANCY GROUP — Mwu \ A — ( Date Apoltunt ooREfs NOTICE TO APPLICA\T If ,n.e• makmg his Ce-tlfteate of X CITY -re Gt4. �oL 6L( OCCUPANT LCAD - Exemption sou liould become subiect to the t\orkers a oLICATICN =OR Es(I"-AR D4V4RE — Compensation pros isions or the Labor Code sou must o-th- F71 with comply with such prosistons or ,his permit shall be -RAILER USE — aGOLoc- INsrEc- ON [� No Spec Knotvl deemed resoked — LICE\SED CO\TR ACTORS DECLARATION ocuPANCY INSPHL-ION) Panic Devices I hereby atffrm that I am licensed under orosisaons of Chapter 3APG-Y PERMIT — (LIST ITEMS BELOW) I 9 (Commencing With Section 7000) or Dnmon 3 of the Bust- NO or E.." ILEI ness and Professions Code and my license Is in tub .orce and yy- effect PARKING 9r4 CH9 RHO o PR oylo Ho B License NLmber L L Clans I LIMITED TIME USE Contractor Date oATf oAT. z I am exempt Item he htensine •equnrements as 1 am n m1 licensed architect o• a registered pr0tessional engineer sIZE OF No or INSPECTOR S z acting in ms proiessnonal emDeut\ ISeL,on 71ff1 Bus- G%ISTING aloe sr ORIGa 3Ia ATURe m mess and P•oressions Code) FINAL APP OVAL O PRESENT use or BUILDING 6 Lnc or Reg No Da,e E I HONE OR1ER BLILDER DECL AR ATIO\ No GxI USE BUILDINGS Iqu NO FEE IIl.y�p ON LOO T Arte IDII� J��u I hereby affirm that I am exempt from the ContraLtor s /- License, Lau for .he following reason (Section 7031 � Bust- ness and Professions Code) No PARKING I as owner of the propert} vnll do the won, and the SPACES PROVIDED t.✓11 structure is not intended or 01fered [or sale (Section / ( 7041 Business and P•ofessnons Code) --" CONSTRLCf1ON LENDI\G AGENCY g PROPOSED us[ or vulLmno I hereby affirm that there is a construction lending agent l for the performance of the work for which this permit is issued(Sec 3097 Cw C) Lender s Name rROP09HO MA% OCC Lender's Address ( I certify that I have read this application and state that the' PERMIT PEE 25,00 above information is correct I agree to comply with all County ISSUANCE FEE ordimnces and State lairs relating to budding construction, and hereby thorize representatives of the) County to enter TOTAL FEE 25.00 • I upon the b ve-mentso d'p rty for inspection purposes 0ti �O ��} SEE REVERSE FOR EXPLANATORY LANGUAGE i Sn ature of Pe ntee Date " WORM RS COMPLNSATION DLCLARATION 76M444 CE 876(1184) M ISCELLANEOUS APPLICATION {� 1 lice, o affirm that 1 have o s'Ccerttfu.Zte Compensation of Consent to self COUNTY OF LOS ANGELES BUILDIN'G AND SAFETY DIVISION LI insure, or a certificate of Workers'Compensation Insuance,or ' a certified copy thereof(Sec 3800,lab C) Policy No Company FOR APPLICANT TO FILL IN ►ulLoixa wooREsa Certified copy is hereby furnishedILOInG 3 LOCALITY x1c •oowu• J Certified copy is filed with the county budding inspection LOC ALITYr• NEAREST department `.f CRoss ST Date Applicant NEARESToisrRl No awgyP TTP[ eaSao eY CNOSS By D� S[ CON°r CERTII ICATE OF EXEMPTION FROM WORKERS' LEGAL •C�' COMPENSATION INSURANCE v[SCRIPriox I LOT No ISLOCK 1°"""' (CIACL[) E arwrMwrow a[cono LOCAL no or SLOGS (This section need not be completed if the work involved rwwcr xo►ON LOT usK aoNK v[mwL conDITio NS by the permit is for one hundred dollars ($100) or less) uSE of SIZE OF LOT KXIETING BLDG 1 certify that in the performance of the work for which th J permit is issued, I shall not employ ;any person In any mann OWNER of buildin U a1 as to become subject to the Workers' Compensation Law MwIL OCCUPANCY GROUP wvvw[a• Date Applicant � u NOTICE TO APPLICANT If, after making this Certificate of CITY NNos OCCUPANT LOAD N 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 TRAILKR USKGKOLOGY INSPECTION ❑ E] No Spec Knowl deemed revoked I I(I NSED CONI RAC FORS DECLARATION OCCUPANCY INSPKCTION ❑ Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter SAFKTY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Bow No OF EXITS ness and Professions Code, and my license is In full force e $PAn effect IDe of business C S w[ao � Pwovio[v vAe License Number Lic Class LIMITED TIME USE contractor Date aAT. DA TU 1 am exempt from the licensing requirements m I am a licensed architect or a registered professional engineer SIZE or no or INSPECTOR a acting in my professional capacity (Section 7051, Bus- EXISTING BLDG Srowl[a naxwru RE Mess and Professions Code) FINAL APPROVAL �^ Lic or Reg No Date P^euxr u°[ or BUILDING I IOM] OWNI R IIIIII DLR DI(I ARAIIONno or uunxo •uuolxoS ON LOT ANo uSo D I `` hereby affirm that 1 am exempt from the Contractor's License I aw for the follouing reason (Section 7031 5, Bow ness and Professions Code) NO PARKING E] I, as owner of therPe ro rt udl do the work and the °PACKS PRCVIOKO structure is not intended or offered for sale (Section 7044,Business and Professions Code) (ONSTRUCI ION LENDING AGENCY PROPo°m USK or BUILDING 1 hereb) affirm that there is a Construction lending agency for the performance of the work for which this permit is issued(Sec 3097 Cry C 1 Leader s Name PROPOSKO MAX oca I ender s Address PERMIT FEE 25. 00 1 Certify that I have read this application and stale that the 1 above information is correLt I agree to Comply with all County I Issas ANCK FKK Ordinances and State laus relating to budditg Construction, and hereby authorize representatives of this County to enttt I TOTAL FEE 25.00 upon.*e above-meet ned r'bperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE XR ,wb Slgnliurc of Penn tim Date i - \\ORAirm CO\IP have a ON DCCLof \TIO\ CE 87 a MISCELLANEOUS APPLICATION I CE er5 111 ear /-t 1 hereby affirm that I have a s Connie o[ coInvar to self ' COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �IILJIII mwte or a Lenditate of Workers Compensation Insurance or , , '-1 a Certified copy thereof ISec 3800 b C) Pol[cv NO op n AO (-o e 1 2ljf 'F��O 9 - Q�Tr FOR APPLICANT TO FILL IN •ulLn na �7 Aoow [• Cenified Lop, Is hereby furnished QUILOInG E Aaow[[• Old / e C Lo cA LIrY Certified copv Is died with the Lounty budding inspection Pd rt LOCALITY nuw[aT ewo[[ [r DateV—/F& a hunt ]�'SLi>�'e ARear PP !!-- OIf TRIC NO 4 V• TT.6 . 659QO aY cRo[s SrG fi consr i CERTIFIC4TEOF EXEMPTION FROM I\ORkERS LEGAL CO\IPE\S \TION INSI R\\CE oe ScwnnoN Lor vo aLoeK NO, ICIwCL[I STAT[ MAJOR SECOND LOCAL NO OI RLOO• by t perm need not he completed ll the work m,leis I rwwc- now on Lor use zGn[ SP[cuL CONDITIONS by the permit Is for nor hundreJ lull its ISI001 or less ) + u[e or SIZE Or LOT f` eYnnnc RL04 I ,erttft •hat �n he orr ornan[.c n he ,nr� 1• ,luck his y permit is Issued f ,bull got mv the 4o an, pr on n m, manm.r g OWNER � w as to becoe �ublea the bonkemn ,l rs Cooensaon Las AA'L / I g Ao o OCCUPANCY GROUP Datc \orhLant L $P NOTICE TO 4PPLI( \\T If .iter mak. t 1115 .:e•t¢iLa(e at % I-- G"Ltpc ,"L/ T' OCCUPANT LOAD E,empuon lou hould become ,ubleLt o he Isorkers APPLICATION FOR E UT HARCWARE Comu oenston oro,isnens at ,he La DO[Coue ou -oust tonh- V ' „nh Lomnh lnD L,I ']•o\15.unS r 11, "e•111t .1311 bL -RAIL=R ISE OQOLJ4Y INVCC- On Flo $PeC \nOwl G deemed re,oked LICENSED I O\TR 1CTORS DELL W \TIO`, ocu.,Nc• LrsPcc-ION B Panic Devices m I hereb, at um hat I am licensed under provisions or Chawc, SarErY PERMIT ] lS Ruowi ' 9 Iwinmenclre ,1h Seaton 7000) of Dnision 3 of husr Ire+ e Bush- No Or EXITS ness and Prntessmns Code and m, hLenie s In ull orce and o(e l.t PARKING ogsRED ovl0[o LlLense Numbe L L 1`135, LIMITED TIME USE COWTIL Or Da.- G•T[ o[.[ I tin •Lmpt ouw hl i,,ns ng ecuve nenc, , I -it a ' hLLnsld 11,111tel Or I ectstr,d Iratesetonil ZE or vor Ins.[c- Al s j 1Ctin2 In 11 01`011151Jna1 .3nh f Sh Oil • BLIC =KIt- m 9L]4 1 a10RI¢3 91GNA UR[ mess and P•otessions Cadet Lu or RL_ Va "ESE IT ISE or 'a WILDIIG FINAL APP VAL � DILL = I HOME D\\VER RLILDCR DL(L\R 11`101 NO or EXISTING RUILm NG[ � on Lo- anO ISE I hereb, Ilium hat I Im esempi 'r,m Ire ContraL,or, I 1—mense Law `or he Lllo,m- 11111 -h, wit -0-1 - 31111 ness and P,Oressions( Jdei No PARKING .PACQS •Roy m[o 1 as ),Liter of he orop rn ,IB du hL ,ork and he - - struc ire Is 'wr m[endLd or Otte Ld ar 1e )e, ton 1 -041 Bu,iness Ind ProresawnsC KILT t ONSTRL CTIO\ I LVD[\(I wEV 1 X PR oeos[o age Gr RUILO..G I hereh, at[= that here IS A LnnSIML[ion lending agent I for the pen ormanle of the cork bur whish this permit is pp Issued ISIc 30Q- C,, C i Co Lender 5 Name Pworo[[o TAX OCC T LLndLTI \ddress 1'I I - PERMIT FEE 25.00 P-•' P+ I Lernfv, that I lu,e read this application and ,um ,113[ the abo,e uuormatwn is Lorrect I agree to Lompl, with all Counn ISSUANCE FEE orduuners and State taus relating to budding constTaLtion D3 Ind hcrebv authorize repmwntatncs of this Counn to enter 1 TOTAL FE[ 25.00 upon the above menuomd pro peat) lir mspe,.non purpoxs O SEE R[\FRSE FOR E%,PLaN aTORY LANGUAGE �a 7 r. ro - n \\ONAIRS ( Of•IPI NSAIION UI(L.\RATION 761 CE 87765 111 BAI MISCELLANEOUS APPLICATION 1 hereby affirm Lett that I have a certificate of consent to self COUNTY OF LOS ANGELES ' ' BUILDING AND SAFETY DIVISION mace.or a urtiOca to of Workers'( Insurance or . U I urtrhrd appy (hereof(Sec 3810,fab C) Pohl) No _ __l amp my_ FOR APPLICANT TO FILL IN BUILDING ADDRESS Cenlhcd Lo Is hereby furnished BmLDNSG P) y 46116 N M CI j3LVD LOCALITY XX Aoow[SS Certified aopv is filed%%Ilh the county budding inspection Locwurr O cwo.i i. dep urtmcal XX LEC C A q /7 Disc___—___ _Applu-ml_____ NEAREST )_)yW C"R t�ZU DISTRICT No GROUP acrK v cESSED Br cwoas Sr M ( I R I II I( A I1 OI rXEMPI ION 1 ROkf WORKFRS LEGAL Icy (OAIPI NSA[ION INSURAN( I oeacwvnOR Lor No BLOCK ^w• 'D"^^• (Clop.LAI arwrE Mwaow SECOND Lout wo ¢4 6 no or Ba.DGS /L I rh I< section need not be completed it We work Involved TRACT MOB ON LOT USE ZONE SPEmwL CONDITIONS by the permit Is for one hundred dollars (5100) or las) r u[E o SIZE or Lor Tj0 X 'b0 [x1aTIRr 6 ELoo ofliLe. 11: 1 sent i that m the pCnot man o of the work for which this ut I% n Haled, I ilii l not employ any person many manneXX ov.NEw of building a. n ht hrrvnm sulgLa l In IhL Rorker< (imptnahon I aws /Aa OCCUPANCY GROUP � pe MOAILow[aS 431 LowrmN J' vl c, A Uatc _ — Apphnnl u NO I K 1 10 APPI R ANI If Ifter making lbn Certi icate of CITY '(�p�PL.E C1T`( noL gid-2 26 OCCUPANT LOAD N I vemphon )on should become subject to the Workers APPLICATION FOR EXIT HARDWARE (ompensatiun provisions of the Labor Code you must forth- ❑ with comply with wall pro%Imnns or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spee KnoWl d(cined rc%okLJ I R I NSI 1)(ON I RA( IONS DE(LARATION occurwner INSPECTION ❑ Panic Devices I hLrth) Ttfum that I am licensed under provisionsof(hapter i SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commenting with SCLtmn 7000) of Division 3 of the Busy No or Exrre Hca and I'rufcamns(side TnJ m) license u m full force aulX — elleLl Name of business Pwvwain° ww0 O LiPwovlD[o 1 d reu I ILm Number _ —_ IIL (lass 50Q 4 A55�' INC — LIMITED TIME USE (onlnLlir _ _____ __ (Yale— —_— ow+S DATA I rm exempt from the licensing requirements u I am a luensed UChilecl or a registered professional engineer SIZE or No or I INSPECTOR ANe acting In my professional Lapraly (Section 7051 Bus EXISTING BLDG SroRiu mess and professions(ode) Pw ESE Nr USE or BUILDING FINAL APPROVAL I ic ser Reg No, Dale A �y IIOAII O\\'NI R 111111 UI R UCC( ARATIONNo Or uunwG BUILDINGS DN LOT AND USX t- '— I hcreb) ilium tlut I un exempt from the Contractors I uense 13W for the Iollo"ing roam ISCLIIOn 7031 5 Bum news and Protcsmons Code) NO PARKING 1 n oa Her of the prnperq w [PACES PROVIDEDill do the work and the � structure Is wit Intended or offered for efle (Section - - 7044 Bu,arlm and professions(IAe) (((NSI R(I( I ION I LNDING AGLNCY PROPOSED USE or BUILDING I barb) afhnn tint there is n conslmclton lending agency lir the perfomul of the s%otk for "bull this permit Is issued(Sec 3097 (ry ( 1 I ender s N line PROPOSED HAA-OCC I LlidLr s Addres< PERMIT FEE I certdy that I base ruJ this ipphnuon TnJ slate that the ibove inform ition w LorITO I igrcc to coinpl) w Jh all(ounly I ISSUANCE FEE ordunncea and State laws relating to building construction, hereby authome reprecenlatwes of thus County to enter TOTAL FEE 25.00 opo the above mentioned pn,perrl for inspection purpose% SEF REVERSE I OR EXPLANATORY LANGUAGE XX •1) ie / 1 � i d l'. n�� 11 n