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HomeMy Public PortalAbout5827-5827 1/2-5729 TEMPLE CITY BLVD_Miscellaneous__ I y y WORKERS'COMPENSATION DECLARATION ' 44 CE 875(71.84) WTSC E L LA N E O U S APPLICATION CE$ I rbaffirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, o or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.C.). t_J Policy No. Company FOR APPLICANT TO FILL IN BU,1LDING �f Certified copy is hereby furnished. BUILDING ADDRESS _ 4;?7 / ADDRESS�1-7 (. M b Uy'd, LOCALITY i Certified copy is filed with the county building inspection LOCALITY NEAR EST department. CROSS ST, Date Applicant NEARESTc DISTR I� G pGRO P TYPE G£SSED BY CROSS ST. .3 jj(/ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MA. HIGHWAY NOOF LDG$, IV O; (CIRCLE) STATE MAJOR SECOND LOCAL . (This section need not be completed if the work involved TRACT NOvr ONBLOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (5100) or less.) USE or { ,I SIZE OF LOT EX STING BLDG. I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner OWNER _ _ gr ��O�t Z f� so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP V woDRESS fe Lz�� (�L Zrt GI/ d 1 Date Applicant g C.A410G0C GS TEL. `738 OCCUPANT LOAD NOTICE TO APPLICANT: If,after making this Certificate of tlxY No. ,T.(o ,Z. -- Exemption, you should become subject to the Workers' i _ Compensation provisions of the Labor Code,you must forth APPLICATION FOR EXIT HARDWARE: 1 with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION deemed revoked. E GI No Spec. !<nowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$[ Panic Devices I hereby affirm that I am licensed under provisions of Chapter n ) SAFETY PERMIT (LIST ITEMS BELOW) N 9 (commencing with Section 7000) of Division 3 of the Busi- Na. OF EXITS ness and Professions Code,and my license is in full force and f(�tI effect. PARKING REWD �! PROVIDED I I y SPACES l 2 o License Number Lic.Class LIMITED TIME USE LL fNA Contractor Date LATE DATE W 1 I am exempt from the licensing requirements as I am a FROM: TO: m f licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S Z acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STQRlES SIG URE m iness and Professions Code). U PRESENT USE OF BUILDING FINAL APPROVAL U Lic.or Reg,No. Date i HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ,y ON LOT AND USE n I hereby affirm that I am exempt from the Contractor's ; 1 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): I NO.PARKING I, as owner of the property, will do the work and the ti SPACES PROVIDED structure is not intended or offered for sale (Section i 7044,Business and Professions Code). { CONSTRUCTION LENDING AGENCY X` PROPOSED USE OF BUILDING i I hereby affirm that there is a construction lending agency 6 Q 1 for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Z Lender's Name ID PROPOSED MAX. OCC. Lender's Address i I certify that I have read this application and state that the PERMIT FEE 25.00 above information is correct.I agree to comply with all County ISSUANCE FEE t—* TM ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL.FEE 25.00 upon the above-mentioned property for inspection purposes. %r D�i rt 1e � SEE REVERSE FOR EXPLANATORY LANGUAGE 1" Clt:n ltnre of Permittee Date a _ Frn WORICL-RS'C'OMPLNSAIION DLCLARtIflON i11111 MI5GELLANEOUS APPLICATION I hereby affirm that I ha eertil'ieale of* �,uhent t„ ,eh C'OUN'l l' OF IOS ANGFI FS BliII.DING AND SAF-ETY DIVISION Il 1 insure,or it certificate ul \\urhers•olinpcn,:nunl lu,ul.ulce.or a certified cup) lhcreol (Sce. moo. I al). (•.1 Policy No. -• Company FOR APPLICANTTO FILL IIJ BUILDING BUILDING ADDRESS ADDRESS ❑ Certified copy is hereby furnished. .;5 g77— -T MPL)_; CA LV1 _ LOCALITY ❑ Certil'ied copy is I.ded with the cuunly building In•.I,rcllun CITY_ �y -- ziP -- — department. IP-J\P� L/t_f �17�� — NEAREST CROSS ST. Date Applicant SIZE OF LOT INO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY 1 CERTIFICAIL OI' l:Xl:N1P11ON FROM WORKI.R.S' - -- — (' ,tet OMPL'NSAI7ON INSUR AN( l: Trracr CONST. C BLOCK LOT NO. MAN HIGHWAY �• _ No ,CIRCLET STATE MAJOR SECOND LOCAL (This section need not be completed if Illi• viork ill%ohed ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS r' by the permit is for one hundred dollars (S 1001 or Ie%%.) e — t certil' that in the performance tit' the "ork IIv ahwij 1111, +.i I permit is issued. I shall not employ an) person nl .sly ru,uuler ��E so as to become suhjccl to the Workers' (umpen,aliul( Lau,, (ADDRESS , OCCUPANCY GROUP 1, IS1 Date Applicant CITY �� � z)p 1790 -- NOTICE TO APPLICANT: If. alter making this Certificate P� OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code.you must 1`01thwilli Comply Will] SACT( pro%15111115 lir this permit %hall be deemed TRAILER USEE] L-1 GEOLOGY INSPECTION�I I revoked. No Spec.Knowl. 1:1 ! LICENSED C'ONTRAC'TORS DLULAR \'I ION OCCUPANCY INSPECTIONrr�� Panic Devices ❑ I iI hereby'off Irin that I am licensed under provisions of('hllpll'f SAFETY PERMIT O (LIST ITEMS BELOW I 9(commencing with Section 7000)of Di%inion 1 of the Business NO.OF EXITS and Professions Code,and my license is in full Ibrce and effect. PARKING• REq'D � PROVIDED D License Number l..lc. ('I;[-,s SPACES 1 I Contractor Date -- —•— ------ -----•---- --- ----- LIMITED TIME USE ElI am exempt from the licensing requirementsas I :1111 it DATE DATE FROM: TO: E licensed architect or it registered prolessional engineer :ICllllg II) 111)' pr(1fL`ssll,ll:ll L'il1)ill'll) (Section 7(li 1, ltll,lll('s, SIZr OF NO.OF 9 INSPECTOR'S 1 EXISrIN(.B1.0G. �� STORILS 1 SIGNATURE and Professions Code). ----- —_-- _—_-- - I Lic. or Reg. No. Date PRESENT USE OF BUILDING v���I FINAL APPROVAL IIOA9l OWNER-lillll.l)I.IL I)I.l I..AI(:\I ION r„I Dr 1 XI_.IINGBUILDINGS I ,IN 1.07 AND USE I hereby affirm that I ani c\cnipt front the Contractor's i Ir(ns( - -- ---------- -- - --- Law for the lolltming reason tSectiun 7011.1, Business and _ 1 Professions Code): NO.PARKING El L as owner of' the properly. „ d ill ., the ,,,,rk .Ind thSPACES PROVIDED r — — -- --- ---- structure is not intended or utleled I0i sale(Seellull 1111.1. PROPOSCE)USE OF1311ILDING I 13u5ine5s and I'rofession5 CONSTRUCTION LENDING AGENCY hereby affirm that there is a cunstrucuun ICndiue the performance of the uork for „hick this permit is Issued - --" ------- -- ul (Sec. 1097.Civ.C'.). PROPOSED MAX.OCC. I Lender's Name - _ APPLICANT I mejT, • TE4 NO X VA. tlr4 bJC�TRAV(�ITQAI�I Dz10-�g 3;oc Lender's Address ADDRESS 1 certify that I have read this application and slate 111,11 the above information is correct. I agree to Comply Willi.111 r(1111111)• PERMIT FEE I ordinances and State laws relating building construcuan.and hereby authorize repres ntative•pF this County to enter upon ISSUANCE FEE the •bove-menti a ropert• o )cetiun purposes. �1 I TOTAL FEE X SLE REVERSE FOR EXPLANATORY LANGUAGE Signature or P nnittee p.qe f { I i WOILICJ:K.� CUIV1Y1r)VJAl1UlV LCI.LAt(Al1VIV 20-0063DPW12/90 1Vll�L.C.LVV:� H!''1''Ld1L.H1 1VlV 4; hereby affirm that I have.a certificate of consent to self COUNTY OF LOS-A' N'GELES 'BUILDING.AND SAFETY DIVISION 1� • mre,or a certificate of•Workers'Compensation Insurance,or - • `I I i� certified copy thereof(Sed:3800,Lah C.)- I licy•NO. Company FOR APPLICANT TO FILL IN BUILDING Y I- "• BUILD IVG A ADDRESS copy.isheby: urnishedA� Certifie 19 1 '• ertified copy is filed'with the county buildin nspection cl NEAREST•I I . ZIP NEAREST d artment � CROSS Sr. Date %' Applicant SIZE L T NO. BCDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CE ICATE'OF•EXEMPTION FROM ORKERS' CONST. C (' F COMPENSATION INSURAN E TRACT BLOCK LOT No. MAP HIGHWAY k (This sectio need not be completed if he work involved I "� IClwclel STATE MAJOR SECOND LOCAL.. P ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS O I by the perms is for one hundred doll rs ($100) or less.) ( I I.certify that in he performance.of t work for which this i�r er ,T I permit is issued'I hall not employ an person in any manner I so as to become su 'ect to the Wor rs' Compensation Laws. A ss t OCCUPANCY GROUP a ( I Date Applic nt . c z) NOTICE TO APPLICA If. a er making this Certificate '"' OCCUPANT LOAD of Exemption, you shout be a subject to the Workers' 0 APPLICATION FOR Compensation provisions of t e- or Code,you must forthwith EXIT HARDWARE: comply with such provisions r this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ ' revoked No Spec.Knowl. ❑ ' OCCUPANCY INSPECTION Panic Devices ❑ LICENSED CONTR S DECLARATION I hereby affirm that I am tic Sed der provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) ( I 9(commencing with Section 000)Of iviSion 3 of the Business 31 game o Business NO.OF EXITS and Professions Code,and y license is ' full force and effect. . PARKING• D D ' I License Number Lic.Cl s j � � SPACES REQ'D PROVIDED I I I Contractor Date U LIMITED TIME USE i DATE DATE ❑ I am exempt rom the licensing requiremen as I am a • I FROM: TO: licensed ar itect or a registered profession engineer acting in professional capacity(Section 7051, usiness SIZE OF NO.OF INSPECTOR'S '{� 1 ; '• and Profe ions Code). EXISTING BLDG. STORIES SIGNATURE. Lia or Reg. o. Date PRESENT USE OF BUILDING FINAL APPROVAL I I ME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS ON LOT AND USE i I he y affirm that I am.exempt from the Contractor's License La for the following reason (Section 7031.5, Business and ( I P fessions Code): NO.PARKING ACES PROVIDED e 0 I, as owner of the property, will do the work and the structure is not intended or offered for sale(Section 7044,11 PROPOSED USE OF BUILDING Business and Professions Code). I CONSTRUCTION LENDING AGENCY OM 90aJ 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.Q. PROPOSED MAX.OCC Lender's Name APPLICANT( 17-1111 Lender's Address iI certify that I have read this application and state that the A above information is correct. I agree to comply with all County PERMIT FEE I ordinances and State laws ielating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE y- (( .•+ ',I the above-mentioned property for inspection purposes. -- -• . 1, I -! • TOTAL FEE % SEE REVERSE FOR EXPLANATORY LANGUAGE � Signature of Permittee Date '