HomeMy Public PortalAbout4819 TEMPLE CITY BLVD_Miscellaneous__ i 11OR6LR5 CO\IPLNS4TIONDL( L\R4TI0\ 76M"4
675" 1 r 841 MISCELLANEOUS APPLICATION n
1 hcrebA t. 6em that I have a certificate pt Lnnsenf to sett
insure
COUNTY OF LOS -ANGELES BUILDING AND SAFETY DIVISION l
re r a Lerttttcate of oders Cumoenvnow
n Inrante 'IT
,I a certified Lop+ thereof (Set. 3801) Lab C t ,�//
Pellet. No _(orttpdm FOR APPLICANT TO FILL IN BUILDIN Ow¢NS GTY LYE.
Certdaed sop+ is herebt tutntshtd wILOINe Cas / ,
s /` ,
I I El CertJted sops is bled pith (he snunn bulldmc mspetnwD DwesIou urr
n❑ wuurY NeAREST
department Temple City 0.. Sir Gf�
Date \pphLam N.AR.KSSr R??.rrS Dlsr cwypr oc¢.aao by
CR.,,
T OY;rlaO .V/1 Co CON.
CER TITI( 1TE Or L\E1IPTIO1, r ROM tORk.ERS L¢aAL
C J\IPFNS\TION 1\$1 R\\l L O¢scwlPr on Lor nD BLOCK AR
,O Ic'•c L.1 STATS MAJOR a¢cOND LOCAL
NO .l.F BLD64
(This section need not he Lomplefed if the And mt olved -RAC- now ON Lor 'i s s. wN. vecuL co no mon.
by the permit is lot one hundred dollan IS 11101 or less I USE Or
1 I
1 LertJs that in ,hL putnrman.r - t ht t , t o- sh¢'t h912E OF LOT is ¢Ylsrrne eLOO
permit n IssuLd I ,hall not empins mt +e-son i an, mannvOwNCR fI'✓I D �G7/N�7
SO as to heLems .tibieLt O the 1lorke t 'nirenctnn, I Inc Mw L r� OCCUPANC 3RO(,P
AD Dw¢ss i2""t/ Dd-bL
I - Date \pplumni -
NOTICL Cf) \PP1_1C\\T It u e• Taken_ 'IT- P4JA-b� gllDjt tea- L 11530 OCCUPdN
Etemptmi tau Should become ,upirc It, A,, kc-
Compewlion om Islons of ,he Litt— ode fou must tur,h 4POL'CA71C\' C'DF -XI- Ha=r, nFE
I atth tomnn Brth uLh ^rusts n9, III Limit .had be _ A,LEP ase �_ ceDwTY N P c- ev — NO SoeC 'C tr7^d
deemed .,,,.ed
LIC ENSED s ONTR\(.TORS DEC L 4R 4TIO\ OCCUPANCY INSPEC-Ionlu Panic Dev res
I he•ebs athrm hat I am licensed undo-ores istons of(naoter a
r 9 ILommen Lin¢ ntth SeLuon -0001 of Dntston 3 it the Bucr .w r.rY PERMIT ,—" jg!fsT hews PALO v) No or ..ITS
ness and P-ntewons Code and ms hse ice Is to cid tors and
effel PARKING Pro PROVID.D
cI LILLn+e \unihsr _ I c CIA,, L I
LIMITED TIME USE
ConflaLtnf I'a12 ____z TO
awe. v.ry
0 1 Am e%empt from the nsensme rLDUue nems Is I am I
1 licensed archaw or a recistered mteaionil enetneer az¢ OF No Or IN.P.OTCR .
z ]Lfm- n nt protR,Mond 'rI- , s, tot 'n.l Bu, ¢Ylsnnr, ¢Loa a-OPi-_o SIGNATURE
a Ineq a,td l''t1RUILnLI Id.i
IR¢s¢nr Use or BUILDING FINAL APPROVAL
Luc or Rr^_ \o D,
HO11L 01%NI R BL I LUL R DF C L 44 \TIO\ NO OF ..LTINa RLILOtNa.
ON LOT A VO us[
1 lierebs at`um licit 1 am e+cmpt Irum ,hc Contrtstor s � (/
I Ltcane lass to, the folloamc reAson ISLLnon -'CI : Bu,t �'
ness and P•otessfons Code l NO PARKING
1 as ,tuner of the properts ntll do 'he pork and the 'PACES PRovID.o
strut tire is not intended or offered for tie ISe,lion
1 7041 Hutan,,s And Pruttsaons(odL)
(-O\STRLCTIO\ LCNDI\G \GI \Cl b PROPOS.➢ OS. or •UILDING S Fi
I hsrebt Affirm that there is a Lonsmtction lendmc IVLnL%
for thL pLoorma= of the %ork for plush this permit Is
issued ISLE 3097 Cut C I
LendLr s Name
PROPOSED Ax OCC
LLndcr+ \ddrscs __
I 1 certifs that I base read this applimlion and nate that the PERMIT FE. 25.00
above mformtiunn is LnrrcLt I Acne to tomppl} u ith all County ISSUANCE Fee
orduianLes end Slate c rclAnttg fo bu Zing 1011SUutiton
and hcrebv a rc resenfatnes of this Lounty o enter TOTALFEE 2
upon t o e ton pit cit) for mspLLtio Pur >a+
I l� SEL REVERSE FOR E\PLANATORI L[VGU \GT
t IZ
ts nature of mitt 1E,at
i WORKERS COMPENSATION DECLARATION 76M444 M ISCELLANEOUS APPLICATION 1171
- -I hereby affirm that I have a «rtdlate of consent to of CE 875 (11 84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION I
msure, or a certificate of Workers'Compensation Insurance or
1 a certified copv thereof(Sec 3800 Lab C)
Policy No Company cOR APPLICANT TO FI LL ADDRESS
NO ISG T/ q
OOwe
Certified copv Is hereby furnished eu uDlnc LOCALITY
Aoowcsa G�
1 CCerrttifiend Copy is tiled with the Lounty building inspection LOCALITY ent Temple Cit y cnoas er
Dale Applicant n¢Aw ser omrelc no on r TYPE c¢aaEG By
cw a ST
l CERTIFICATE OF EXEMPTION FRO\t WORKERS OaLEGAL e
COMPENSATION INSL R INCE I.L.C.
VO (CIw CLtI STATE MAJOR SECOND LOCAL
VO OP
SLOGS
(This Seet100 need not be completed If the NO[k InVO1Ved BRACT NOW ON LOT use EONC SP¢CIAL CO NOITIO N9
by the permit Is for one hundred dollars (S 100) or less) use or
I _ertify that in the performance of the stork for tshich ,hu al=e OF Lor USX%Ttnc SLOG JILUPULtyI
permit is issued, I shall not emplot an) person n any of
O.NEw
so as to become subject to the Workers Compensation Latta OCCUPANCY GROUP =_
MAIL
AO OR H93
I Date Applicant Al I _
NOTICE TO APPLICANT It atter making ,his Certificate of X CITYvoL p�_ °j0 OCCUPANT LOAD -
E%emptron you should become subject to the Woricers app LIGATION FOR I EY IT HARDWARE
Compensation provmons of the Labor Code t ou must tn-th ❑
I vrth comply with such provisions or ,his permit shall ba TRA,L_w us¢ D GEOLOGY IN are c-ION No Spec Knowl
m deemed retoked
LICENSED CONTRACTORS DECLARATION OCCJPANCY INSPECION$ Panic Devices
T I hereby atfirm that I am licensed under provisions of Chapte•
9 (commenaipt with Section 1000) of Division 3 0[ the BusSAFETY PERMIT ❑ (LIST ire ns aeLOw)
NO OF EXITS
ness and Professions Code and my license Is in full force and
effect PARKING REO Is PROVmeo
SPACES II��JJ
o License Number Lie Class LIMITED TIME USE
Contractor Date OATR GA•.
z
f am exempt from the licensing requirements as 1 am ..
m INSPECTOR 9
I h«rlud architect or a registered protes5lonal en¢meet Slze Or Vo OF SIGN SIGNATURE
o acting in mt protessional apacm (Section 7051 Bus EXISTING BLOB STORms
a mess and Professions Codel FINAL APPROVAL
o PRESENT use or Su1LOlnc
Lc or Reg No Date 1��1
H
HOME OW1ER-BUILDER DECLARATION no or ExmnnG BUILDINGS A O I
I hereby affirm that I am refrom the r y
I License Law for the followinggreason (Section 7031031 5 5roON LOT AND USE
Busr
ness and Professions Code) No PARKING
I as owner of the property will do Lhe work and ihL '"Aces PROVIDED
structure is not intended or offered Lot sale (Secuoi,
i 7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY X PROPOSED use OF BUILDING
1 hereby affirm that there is a construction lending agent) r
I 1 for the performance of the work for which this permit is
Lamed(Sec 3097,Civ C)
Lender s Name
woroe¢G Mwx Oec
Lender s Address
1 I certify that I have read this application and sate that the PERMIT FEE u,DD
above Information as correct 1 agree to comply with JR County ISSUANCE PEE
ordinances and State laws relating to building construction
t 1 and hereby authorize representatives of thunry to enter TOTAL FEE 25.00
upon the above-mentioned property fo ec n purposes
_ SEE REVERSE FOR EXPLAN RY LANGUAGE
.1 r Signature of Permittee Date t
(
I �
WORKERS COMPENSATION DECLARATION 75 Il 1 84)
CE 876 MISCELLANEOUS APPLICATION
CE B
I hereby affu n-th,t I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
mare,-or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
PolANo —Company auuolxa T/
Y P FOR APPLICANT TO FILL IN coo ow[66 � I
Certified copy n hereby furnished Bu uOlna I
XX woow[u / / (�- e.. LOCALITYL_ ��,
Certified copy is filed with the county budding Inspection LOCALITY N[Aw[.T /s
department XX TLS I L e,V CiA- 91 -O eco oE• AT
ZU W cv �-f-
Date Applicant x[ww[eT may. . OISTRICT NO awgu• Tr Pt • 6.[O Sr
ewo6e 6r L WQ✓ yVy.�9Li r /1 conwr
CERTIFICATE OF EXEMPTION FROM WORKERS' L[ST J /�T
COMPENSATION INSURANCE O[6cwlr Tlon LOT No [Loew coo• JCI.CL.) 6rwrE MAJOR •[conn LOCAL
N0 Or SLOGS
(This Section need not be completed if the work involved TRACT xor ON LOT u6E ion[ SPECIAL CONDITIONS
by the permit is for one hundred dollars ($I00) or lea) =1 of
612[Or LOT [wrl}Ixa CLOG
1 certify that in the performance OC the work for which this �
permit is issued, I shall not employ any person in any manneXX Grx[w of building
so as to become subject to the Workers Compensation Laws 6swIL Lrp OCCUPANCY GROUP of
Dale Applicant TEL
�l.✓� LI
U
NOTICE TO APPLICANT If, after making this Certificate of CITY /tw. It Qt� NO I _ OCCUPANT LOAD N
Exemption, you should become subject to the Worker. APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked rwwu[w uaE ❑ GEOLOGY INSPECTION ElNO Spec KrroWl
I ICLNSED CONTRAC FORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
1 hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEM[ BELOW)
9 (commencing with Section 7000) of Division 3 of the Bush No Or EXITS
ness and Professions Code, and my license n in full force anise
eITCLt Name of business III, K G
.PACE[ Sao o L,TLJ PROVIDED
Lu.ense Number Lic Class Tc-..,01- r—h N- RRN A I`ZIC-tl
LIMITED TIME USE
Contractor Date Own Gw T.
1 am exempt from the licensing requirements as 1 am a T.
www INSPECTOR s
licensed architect or a registered professimal engineer SIZE or $ irolilc6 SPECTuw[
acting m my professional capacity (Section 7051, Bus- EXISTING [Loa oUU S -,A I
mea and Professions Code) PRESENT uEE or BUILDING L* FINAL APPROVAL
Lic or Reg No Date ✓h Qv<<e.1
r �^
IIOAII OWNFR-ftl11LDER DECLARATIONno .. Uof ESBBUILDINGS1
NO Lor wNo tie[E N fi
I hereby affirm that I am exempt from the Contractor's V
License Law for the fallowing reason (Section 7031 5, Bust-
ness and Professions Code) NO PARKING / (p
1, as owner of the property, will do the work and the *PACKS PwovtOEo f7
structure Is not intended or offered for ale (Sectior - - -- -
7044,Business and Professions Code)
CONSTRUCT ION LENDING AGENCY Pw OPo.ED OSE Or BUILDING Q V�C Q[i Cu4
1 hereby affirm that there is a construction lending agency _.
for the performance of the work for which this permit is �p A,
issued(Sec 3097,Civ C) c �t
Lender s Name
i
PworoEEO Mwx occ -
Lender's Address - i
I certify that I have read this application and state that the PERMIT r[[ `
above information n correct I agree to comply with all County ISSUANCE FEE r
Ordinances and State laws relating to budding construction,
and hereby authorize representatives of this County to enter TOTAL FEE 25- 001 -
upon the above nip"property for inspection purposes
� -- 11 SEE REVERSE FOR EXPLANATORY LANGUAGE -
XX c.i.+AI. XX '
Signature of Pern cc DTte