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1l'URALRS (OkIPLNSA110N ULCLARAIION
CE 875 111 eAl MISCELLANEOUS APPLICATION {�
CE 876 _ LJ
1 hereby affirm certificate
1 have a Certificate'Compen at mInsur to au COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
msurc, a a certJtcate of Workeri Compensation Insurance,or
a certified copy(hereof(Sec 3800,lab C)
Policy No (omP�;+my 969�0�n�1y(36-- &agls FOR APPLICANT TO FILL IN AoDwiNi r? 7
E] centfied copy is AW69T�",,G70-01 xx woowi�� 4327 Temple City Blvd. LOCALITY
department
copy Is filed with the county budding inspection LOCALITY Temple Cl t Ca. coo..$T
3CXBY
Dale Appltrinl NE A REPT Valley orfrwl Oq., GP cove E*fco sir
CROff ST Y
( I R 111 R AIL OI' EXEMPTION 1 ROM WORKERS' LEST
COA1Pl NSATION INSURANCE -O Ef cwIPTION-GAL
LOT No - - •LOC• - �oP_ _ _ jcl.cL�� _STATE MAJOR Secorv0 LOCAL
No Or BLDof
(This section prm need r be completed ll the work orinvolvedless) TRACT NOW ON LOT USE tows *PECIAL CONDITION*
by the peanut n for one hundred dollars ISI00) or less) ufeci1fTIN0 or LDD �' "T
s /
1 urtlfy that in SIZE Or LOr the performance of the work for which this
is N haled, I shill not employ any perm-- many menne oW„ER of building B.J. Sabin
so n-
u, n to become aitgest to the Workers Compensation Laws NAIL OCCUPANCY GROUP
ADDRESS ELI
Dale— Applicant_ v
NO tICI IO APP(I(ANT If after making this Certificate of urr rTioL0-838-771 OCCUPANT LOAD ,o3
1 xemptton, you should become object to the Workers' —
APPLICATION FOR EXIT HARDWARE
(umpensnhon provisions of the Labor Code you must forth•
unh comply with such provisions or this permit &hall be TRAILER ufe ❑ GEOLOGY INSPECTION ❑ No Spec Knowl
decwed reloked
I R 1 NSI U(ON I RA( 1 ORS DL(LARATION OCCUPANCY INfPwrloN ❑ Panic Devltes
I hereb) afhnu that I am licensed under provrsronsof Chapter SAFETY PERMIT ❑ (LIST IrEMf BELOW)
9 (commenting with Section 7000) of Division 3 of the Boo- NO or EXITS
ness and Professions Code and my license is in full force ail*, Name of business PAwKING
el ILLI
SPACES REG D PRoviOEo
I hulu Numbly _ _ I a ( lass -' -
- — - LIMITED TIME USE
(--nim Llor Date— G.Tf DAT. _
I nm exempt from the licensing requirements Cit
P
ement& as 1 em e Y r Ca. 91780
IlLensed architect or a registered professional engineer SIZE Or �Z 21 S No or 1 yf171 1wfPE CSO R,e
acting to my professional capacity (Section 7051, Bur B
EXISTING L r •TORIES uarvwruRe
mess and Professions Code) FINAL APPROVAL /
1 IL or Reg No -- Date PRESENT USE or BUILDING
Gnu acuring
((OMI OWN[ It 111111 DLR DL(I ARATION NO OF EXISTING BUILDINGS D 1�(P
ON LOT AND UIs I A
I hereby affirm that I on exempt from the Contractor's V L
1 (cense I aw for the full,ming reason ISection 70315, Bust
ness and Professions Code) NO PARKING 20
1, as owner of the properly ssdl do the work and the SPACES PROVIDED
structure Is not intended or offered for sale (Section
7044 Business and Professions Code)
(ONS I RU( I ION I I NDING AGENCY PROPOSED use or BUILDING
I hsreb) affirm that there as a Lonstructton lending agency Manufacturing car audio speaker
Jut the perfunnmLe of the work for which this permit n
issued IScc 3097 (u, ( 1
I ender s Nnme
PROPOSED MAX Dec ”
I rndLr s Addo.ss
I urldy dial I h tic &Lad flus apphsal n and state that the PERMIT FEE
above information as u„reti I agree I mply with all County ISSUANCE FEE
ordinances and Statelaus irlahrWj6 budding construction,
f xnd hereby author cop sent es of this County to enter TOTAL FEE 25-00
J/V\` Upon the ahnve t Jutin pro Pty a ns tion�pyitypo s
X I' XX L?' S1 REVERSE FOR EXPLANATORY LANGUAGE