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Home My Public Portal About5924 TEMPLE CITY BLVD_Miscellaneous__ 14'dRKERS'COb1PENSATiON DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that 1 have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING 02 4 w/ ADDRESS Certified copy is hereby furnished. BUILDING a, P� = C! � LOCALITY ADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST ' department. P ceoss ST. Date Applicant NEAREST / �• DIST ICT NOO GROUP TYPE P 99ED BY CROSS ST. (� 2- COMPENSATION CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL dG COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP/ll�_�� GRCLa; STATE MAJOR SECOND LOCAL NO. OF BLDGS. J� (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (5100) or less.) USE OF I certify that in the performance of the work for which this slzE of LOT EXISTING BLDG. permit is issued,I shall not employ any person in any manner OWNER E'� L. L ooh I o y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o - Date ADDRESS p. Applicant w NOTICE TO APPLICANT: If,after making this Certificate of CITY ('r�� Ivo' 'd' qq OCCUPANT LOAD y 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 USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- ness No. OF EXITS and Professions Code,and my license is in full force and I� effect. PARKING SPACES REq'D D PROVIDED 1�—J License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TOI I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S bNATURE iness and Professions Code). ^ / PRESENT USE OF BUILDING : FINAL APPROVAL � �/ ) �/��/' Lic.or Reg.No. Date C� / C C� 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, Busi- ness and Professions Code): NO. PARKING ElI, as owner of the property, will do the work and the. SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 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.). F (� Lender's Name PROPOSED MAX. OCC. Lender's Address 1 PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances a tats laws relating to ilding construction, and hereby uADJ--24 ' a representatives of his County to enter TOTAL FEE OD the oveioned p perty r' spection purposes. J�,�f SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Per nittee DVe WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent tself COUNTY OF LOS insure,'or a certificate ficate of Workers'Compensation Insurance, ANGELES BUILDING AND SAFETY DIVISIONe,or �-"' a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS �- 7 Certified copy is hereby furnished. BUILDING yp �-7,�J/J ° �/� LOCALITY ADDRESS ,�/t / L�/;';�•/I.L f" ( / T �V Certified copy is filed with the county building inspection CALITY j ` w NEAREST 47 department. to 71TI!11'1 L 0 /;T p CROSS ST. Date Applicant NEAREST r pJ- (' u 1 DISTRICT NO. ROUP CYPEONST. P CESSED BY CROSS IT CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L/J L COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF BLDGS. (This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of a I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. permit is issued, I shall not employ any person in any manner OWNER kq/ Lanw t/ y so as to become subject to the Workers' Compensation Laws. MAIL. ,( /� OCCUPANCY GROUP C3 Date Applicant ADDRESS //`• V t61-C �� V NOTICE TO APPLICANT: If,after making this Certificate of CITY �116 71- 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and C J �S PARKING effect. SPACES RZQ'D PROVIDED I - I LL JJ License Number Lic. Class �� r� 'o' LIMITED TIME USE Contractor Date DATE DATE DI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. f �� STORIES SIG RE iness and Professions Code). ��,lJ PRESENT USE OP FINAL APPROVAL BUILDING,.. (n"'y/,j Lic.or Reg.No. Date i 6 ,�L HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's 1�"1 ltlzi_!-1 l�li 5 135 9 License Law for the followingreason (Section 7031.5, Busi- ness usi (�Y/ rtv e�L v1! ness and Professions Code): No. PARKING I„ �6E4 i AM SPACES PROVIDED II/ I, as owner of the property, will do the work and the V structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 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. Lender's Name PROPOSED MAX. OCC. Lender's Address o OQ I 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 r ting to building construction, and rh%y authorize repres tatives of this County to enter TOTAL FEEuponbove-meiltioned perty for inspection puposesy)C Cyt ,'',`g�•,/v rG�,� �- f �,�.•� SEE REVERSE FOR EXPLANATORY LANGUAGE Sign urge of Permittee t;- Date WORKERS'COM PENSNfION DECLARPCrm IbM•1.1-1 .n_�t„�;,,,AW,r,•�„ MISCELLANEOUS APPLICATION 1 I hereby affirm that I have a cerdrictc of c(m,enl, 10 self COUNTY OF LOS ANGELES I BUILDING AND SAFETY DIVISION insure,or a certificate or Workers'C'ompen,ation Instl�unce.or ' •�l a certified copy thereclf(Sec. 3800. Lab.C.) ,j Policy No. Callipany, FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRESS //�� ADDRESS ? LYJ Certified copy is hereby furnisheJ• t G 04- LOCALITY ❑ Certified copy is filed with the county building iw-pection CITY ZIP � /po `•1 department. I NEAREST CROSS ST. Date _ _ Applicant SIZE OF L 'L NO. BLDGS.NOW ON LOT I DISTRICT NO. GROUP TYPE PROCESSED BY CONST.Iry— I CERTII icaE OF EXEMPTION FROM WORKLRS' TRACT BLOCK LOT No. J COMPENSATION INSURANCE MAP HIGHWAY NO. ICIRCLEI STATE MAJOR SECOND LOCAL (This section need not Ile completed if Illi' Wort. Fi\olved ASSESSOR MAP BOOK PAGE PARCEL C. by the permit is for 011e' hundred dollar4i (7°100) or less.) I USE ZONE SPECIAL CONDITIONS ` OWNERTEL NO. certify that in the performance of the work for \Yhich this _ permit is issued, 1 shall not employ an) person in any manner l t so as to become subject to the Workers' Colmpen,atioll Laws. ADDRESS OCCUPANCY GROUP 2.1 d. Date--- - _ Applicant CITY ZIP NOTICE TO APPLICANT: If, alter makingthis Cel:il'icate I OCCUPANT LOAD 1 of Exemption• you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ 1 revoked. No Spec.Knowe. 1ILL�JJ1I ' LICENSED CONTRACTORS DEC LARAf ION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provision,of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW I I 9(commencing with Section 7000)of Division 3 of the Business NO.OF EXITS It and Professions Code,and my license is in full force Ind.effect. WNW, \z+I"aS5 PARKING• License Number Lie.('I:I,s r/ C �,,, •% f,�t y 7.0 ` SPACES REQ'D � PROVIDED ! I Cont actor Date LIMITED TIME USE i I DATE DATE 1 am exempt from the licensing requirements as 1 am a FROM: To: licensed architect or a registered professional 0,gineer i acting 111 Illy professional capacity(Se'c't lull 7051, IIII,IlleS, SIZE OF NO.OF INSPECTOR'S and Prllle5til11115 Code). EXISrmc BLDG. SrORms _ SIGNATURE Lic.or Reg No. Dietl' PRESENT USE OF BUILDING FINAL APPROVAL D was Q - Y{R- ”� I HOME OWNER-BUILDER I)ILC .ARAI ION NO.OF rxisrING BUILDINGS I oN LOT AND USE I hereby affirm that I am exempt front the C'ontractor's License Law for the following reason (Section 70315• Business and Professions Code): NO.PARKING I El 1. 85 owner of the properO. sill tit, tile \\Urk Illlll IIIC SPACES PROVIDED --- structure is not intended or offered lin ,:Ile(Seclion 7044. PROPOSED USE OF BUILDING Business and Professions Code). I -el I CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a cunsu•uctiun lending agency lirr the performance of the work for which this permit is issacd ' I (Sec. 3097,CIV.C.). PROPOSED MAX.OCC. Lender's Name —._..- ___ ._ . .._ X APPLICA' T taRlIVT • TW646.y / /J Lender's Address ADDRESS .� ,( I certify that I have read this application and state 111111 the SS qd o t above information is correct. I agree to comply with all County PERMIT FEE I ordinances and State laws relating to building construction.and hereby authorize representatives of this County to ente.- upon ISSUANCE FEE the above-mentioned property fi inspectiol pose,. TOTAL FEE ° X rJ r S�� SEE REVERSE FOR EXPLANATORY LANGUAGE , nut re or Permittee Date