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WO12KERS'COMPENSATION DECLARATION 76M444
,.. M ISCELLANEOQS APPLICATION
a . .. ,� ceaTsnt�@a)
1 hereby affirm that 'L have a certificate,of consent'to self COUNTY OF LOS ANGELES - BUILDING AND SAFETY DIVISION
insure.,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.). I I -
Policy No. Companylro ILDING _
,. FOR APPLICANT TO FILL.IN ADDRESS, �36
Certified copy is hereby furnished.- BUILDING .'
I ADDRESS LOCALITY'
<i
aCertified copy 1$filed-with'the C011nty buildinginspection LOCALITY I NEAREST
I -
department: cwoss sr. -
Date Applicant- "I NEAREST _ /1 'DISTRICT NO. GROUP TYPE OCESSED BYE
CROSS .A S �i D Q ON.,.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEST. - d O
.COMPENSATION INSURANCE DEscRlPnorv� '.LOT No. , ' BLDCE- MAP, - _. WAY
OF BLDGS. ':..
No. ( CL STATE MAJOR SECOND LOCAL
-_
(This sectionneed not be completed. If ,the,work InVOIVEd , ' ..TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS ' - •-
by the permNOl it is for one hundred dollais ($100) or.less.) - - US
SE-OF I _
SIZE OF LOT £XISTING.BLO6. - y
I certify that the performance of the:work for which this
permit is issued, I shall not employ any person m any manner, OWNER %:.. &/q - y
so as•to lico subject to the-Workers', Comp satio't Laws. MAIL _ .�- ' OCCUPANCY GROUP 3 - o
I I AOOfl E55
Date_yQl Applicant .LJ!•✓ a R. I, �� c5
NOTICE/TO APPLICANT:if, after making this Cert nate of crrY '' TEL
yi� OCCUPANT LOAD- N
Exemption; you should become subject to the Workers' - z
Compensation provisions of the Labor Code, you must forth, APPLICATION FOR EXIT HARDWARE:
with comply with such pIovislons or this permit ..shall be _TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.. - _ t .
LICENSED CONTRACTORS DECLARATION Otto PAN CY Ii+s PECTIoe Panic Devices
I hereby affirm that I am licensed under provisions of Chapter. swFEry PERMIT EJ ;usT 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, - �- d - — -
effect. PA ti Ki.0
y�� p �� SPACES REO'D D PROVIDED D
License Number •Lie. Class Gl. I"�7s^-' - �1�� l-� r/U T'Y)'l�
LIMITED TIME USE
Contractor Date2. T - DATE
I am exempt from the licensing requirements as I am a - M'e` 1- C Urn - -
licensed architect or a registered professional engineer SIZE of - No. of INSPEOTOR's
acting in my professional capacity (Section 7051, Bus. EXISTING BLDG. STORIES SIG URE
iness and.Professions Code). r FINAL.APPROVAL 7 L '
Llc.oI Reg.No. Date PRESENT USE OF BUILDING II /I
1
HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS
ON LOT.AND USE _
hereby' affirm that I am exempt from the Contractor's
License Law for the-following-reason (Section 7031.5, Busi • .Lq-, iL r_i
ness nd Professions Code): NO. PARKING - I • -
as owner ofthe property, will do the work and the SPACES PROVIDED ,. 1 t I t":
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
Tk.
PROPOSED USE OF BUILDING
_ . CONSTRUCTIONZENDING AGENCY
I hereby affirm that there is a construction lending agency -CHNIN jE
for the performance'of the work for which this permit is -issued(See. 3097,Civ.C.). "
Lender's Name
PROPOSED MAX'. OCC.
Lender's Address
5
PERMIT FEE
certify that I have read this application and state that.the
above information is correct. 1 agree to comply with all County- ISSUANce FEE
ordinances.and State laws relating to building construction,
and hereby-ahthorize-representatives of this County to enter TOTAc'FEE A S
U po i theabove-mentione propery for inspection pure ses. EE REVERSE FOR EXPLANATORY LANGUAGE
V (02 a-r /< . �GV9�
Signature of Permittee ate
r' Of LOf tt�yc
-'712- COUNTY OF LOS ANGELES
- ` DEPARTMENT OF PUBLIC WORKS
`'fmonw� / SAN GABRIEL VALLEY REGIONAL OFFICE
THOMAS A.TIDEMAN50 N.Direcbr BUILDING AND SAFETY
125 S. Baldwin Avenue
Arcadia, CA 91007
(818) :574-0941
MICROFILM INFORMATION
Record Search
1933-1954
Building Address: g33(p �-by A WC t- Locality TeI.-4� -- Ci} �
Previous Address �q (oz vOc.A WC, Tew jp�e— Ci �� �C � {y)
Tract No. Lot No. Lot Size
Building Pe t # Issue Date Final Date
Descript' n of Work
Sq. Ft. .-
Building mit # Issu Date Final Date
Descrip ion of Fc rk
/ Sq. Ft.
Building��^�Per # Issu to Fin Date
Descrip7gn o Work
\\\\ Sq. Ft.
Building Permit # Issue Date Final Date
Description _o W
\\\\JJJ\ q. Ft.
Building Permit # Issue Date Final Date
J
Description of Work
Sq. Ft. Z /
Sewer Permit # Date Issued /
Private Disposal System / Date Inspected /
Public Sewer Connection
Date By: ��