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Home My Public Portal About9156 LA ROSA DR_Miscellaneous__ t y-WORRERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that I 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.C.). Policy No. CompanyFOR APPLICAN TO FILL IN BUILDING _ ADDRESS U`� Certified copy is hereby furnished. AUDDRILDINSSG LOCALITY E FCertified copy is filed with the county building inspection OCALITY NEAREST department. CROSS ST. Date Applicant AREST DISTRICT NO GR U YPE PROC ED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SEC D LOCAL NO. OF SLOGS. (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 I certify that in the performance of the work for which this E OF LOT EXISTING BLDG. 0 S permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. IL r s OCCUPANCY GROUP EE2 o ADDRESS I • Date Applicant Cv3 NOTICE TO APPLICANT: If, after making this Certificate of CITY NOI. OCCUPANT LOAD 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 PER T ❑ (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 effect. PARKING REp'D O PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ❑ 1 am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSP CTOR S acting in my professional capacity (Section 7051, Bus- EX TING BLDG. STORIES ISS- iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date 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. PARKINGR R - +v " 0 I, as owner of the property, will do the work and the SPACES PROVIDED 09,06" 9�O 6 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.). Lender's Name PROPOSED MAX. OCC. _ Lender's Address /l I certify that I have read this application and state that the PERMIT FEE951 0 �v above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE d� n the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 75 CE 8 , MISCELLANEOUS APPLICATION - CE 875(11-84) I laffirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insureure,, o or a certificate of Workers'Compensation Insurance, e,or , a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ('� ADDRESS Certified copy is hereby furnished. BUILDING bre LOCALITY ADDRESS1=6. 0 Certified copy'is filed with the county building inspection LOCALITY NEAREST ' department. CROSS sT. �,t, Date Applicant AREST p� p�� DISTRICT NO. GROUP TYPE IP ESSED BY CROSS 9T. VIL I/� LUCNL -¢J'CL� LOQ yy CONS • t CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v ,( COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS.* (This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) I USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this- o permit is issued, I shall not employ any person in any manner OWNER sD so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP [�� o Date Applicant ADDRE 61 �. W t TEL. OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of Iry (1/ l� No. � Exemption, you should become subject to the Workers' z AP_LIGATION 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. El - LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices EJ 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 effect. PARKING REQ'D PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a regis(ered professional engineer SIZEOF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code).' FINAL APPROVAL ' Lic.or Reg.No. Date ESENT USE OF BUILDING vbl tk¢see` b4wjqcase HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILIDINGS 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 _ 5 4 9 A' 7044,Business and Professions Code). .}}{{ OPOSED USE OF BUILDING # 0-0,* 8 8 CONSTRUCTION LENDING AGENCY , ' I hereby affirm that there is a construction lending agency G_ �� • 0 0 0 o e • for.the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). V 09..-19-86 Lender's Name PROPOSED MAX. OCC. Lender's Address 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 and State laws relating to building construction, and hereby aul4arize representatives of this County to enter TOTAL FEE upon e-mentioned propertfor insp ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date RuOrj KERS'COMPENSATION DECLARATION CE 875(2-80) M,I SC E L LA N E O U S 'A P P L I C AT I O N -_I hereby affirm that I have a' certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION -`'insurei)r a certificate of Workers'Compensation Insurance,or a certified copy-thereof(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING �� _ ADDRESS D Certified copy is hereby furnished. BUILDING ADDRESS 9156 La Ro s'a Drive LOCALITY D - ' ' Certified copy is filed with the county building inspectionNEAREST r P department. OCALITY .Temple City, Calif.91780, CROSS ST: Date Applicant EAREST DISTRICT NO.,. GROUP TYPE PROC SSED CROSS ST. Ericineda _ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL' V COMPENSATION INSURANCE DEsc RIPTION LOT-NO. �- BLOCK MAAp �r - MIGM WAV STATE MAJOR SECOND LOCAL } NO. / (CIRCLE) NO. OF BLDGS. � "C (This section need not be completed-if the 'work involved., TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0 by the, permit is for one hundred dollars ($100) or less.) USE OF V SIZE OF LOT EXISTING 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. �NER Communit Dis 6sal O so as to become'subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP U 9156 , La Rosa Drive W ADDRESS - LU Date Applicant a _ _ Cn En j �ry NOTICE TO APPLICANT:-If, after-making tlils Certificate of CITY - Temple Cit TNoL. 2• 3� /� OCCUPANT LOAD ..Z Exemption, you should become subj ect, to' the Workers' APPLICATION FOR EXIT HARDWARE: Compensation proXisi' ON FOR EXIT HARDWARE: of the Labor Code, you must forth- with comply with-such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ' ❑ C1No Spec. Knowl. a deemed revoked. _ Panic Devices LICENSED CONTRACTORS DECLARATION occuPArvcr INSPECTION I hereby affirm that I am licensed under provisions of Chapter - SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF-EXITS 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in'full force and PARKING effect. _ SPACES REO'D O PROVIDED D License Number Lic.Class LIMITED- TIME USE Contractor Date' DATE DAT E OFROM TO - 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 NATURE " iness and Professions Code). FINAL APPROVAL RESENT USE OF BUILDING Lic.or Reg.No. Date Lithography HOMEOWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS' ON LOT AND USE I hereby affirm,that' I am exempt from the Contractor's x4,22 2 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): No. PARKING ;#.o o'o o 8'8 SPACES PROVIDED D I, as owner of the property, will do the work and the � _ o s o 0 a 0 0,12 structure is not intended"or offered for sale (Section. 7044, Business and Professions Code). 0 I6 3C_8 2 OPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCYCommercialPrintin I hereby affirm that there is a construction lending agency g for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. . Lender's Address PERMIT FEE 25.00 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 and State laws relating to building construction, and hereby authorize representatives'of this County,to enter 'j TOTAL•FEE 25.00 (Pay to 'C i ty-, Of -Tem'](2 C i ty) up o the above-,menti one o ty for inspection yurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ur f ermittee, ate ; WORKERS.'COMPENSATION DECLARATION CE 8754(2-80), M ISC E•L•LA N E005,•A PPL ICAT ION I hereby _affirm that I-have•a certificate of consent to self - COUNTY-,OF- BUILDING AND-SAFETY DIVISION insll�, or a certificate of Workers'Compensation Insurance,or,, -a certified copy thereof(Sec. 3800,Lab. C.) " -Policy No. Company FOR APPLICANT.TO FILL IN BUILDING •, - ADDRESS Q,'Certified copy Is,hereby furnished'. - 410BUILDING o t yJ - LOC ALITY, - - Certified-copy•is filed with the county building inspection NEAREST LO C ALI TY�,' /w/ - department'. , •d ��. I CROSS ST. - Date Applicant J' EAREST F; / DISTRICT NO. GROUP TYPE PROC SSFyD B CROSS,ST., E �/t,/I• - CONST. .. . '• . . . 's •off.. /3` V CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION, LOT NO. `BLOCK, 'IrIA p' �HIGNwAY+, COMPENSATION'INSURNNCE //,�� STATE-MAJOR SECOND LOCAL _ _ NO.�(f� (CIRCLE) - NO. OF BLDGS.- - (This section need not be'coinpleted.if the work•involved TRA CT Now,ON LOT' USE ZONE SPECIAL CONDITIONS �.% _ O by the permit is, for one hundred dollars ($i00),-or'"l'ess.), - _ ' L) r - USE OF - ' ' BLDG:- SIZE OF LOT -� EXISTING / - cc 1•certify that in,the'perfoririance�of the work for which'thi's a /�'- ' 'permit As,issued, I shall-not employ ariy•�person in any manner WNER � O CO'h%J/y►l/ll/�f ' so as to liecome.subject•to the Workers''Compensattori-Laws. Y AIL OCCUPANC ,GROUP_IOM ADDRESS IICY G S.# ..�; + ®'•- W Date Applicant, ; ' N TEL. z NOTICE,TO;APPLICANT:,If„after making-this-Certificate of. Cirv,'� ?% `��, 'No. -'33. L• OCCUPANT LOAD;;.'” ( _ 'Exemption, you- should-6come•subject, 'to the Workers' AP LIGATION FOR " EXIT.HARDWARE.- `Compensation provisions of the, Labor Code,-you must forth-, with, comply' with "such provisions 'of this permit `shall be TRAILER,USE "GEOL`OGY INSPECTION 1 ❑ _ - 'No Spec.'Knowl. �'•• deemed-revoked. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY-iNSPECT16N , P81lIC Device Thereby•affirm that., am licensed•under provisions of Chapter SAFETY-PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing,with Section 7000),of.Division.3 of the Busi- ness and Professions Code, and my license is-in' full force and- Pw RICING. effect. REO'D O PROVIDED - - e SPACES r License Number •Lie.Class LIMITED=-TIME USE Contractor Date DATE D AT E ' - • ' : I -• FROM: , I am'exempt from t- the licerising.,requirements as am a licensed architect, o%y.a 'registered- professional engineer SIZE OF - NO. OF - INSPECTOR'S acting in' my professional capacity, (Section'705), 'Bus EXISTING BLO G. STORIES SIGNATURE inessand'ProfessionsCode). `.e FINAL APPROVAL s 1 7 -• - RESENT USE OF BUILDING 6 Lic.'or`_Reg.No. 'Date , b '` " 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< + ' :. .( SP-ACES PROVIDED I; as owner of the property, will.do they work and the ;# - Y3 structure, is not intended or offered ,for'sale (Section `• - �' 7044, Business-and Professions Code).- G� ' t s V POSED USE OF BUILDING / / ' o h # e'le o' ,B B :CONSTRUCTION LENDING AGENCY I hereby, affirm-that there is a construction lending agency "' o o_to eI'o'e:o a for ,the performance of the,work'for which this permit is l issued (Sec. 3097,Civ.C.). �Jr 21—$2 „ Lender's Name PROPOSED MAX. OCC. , Lender'§`Address PET RMIFEE": • .. - - ��- I certify that`I have read this'application and state that`the' above information is correct_I agree,to'comply•with_all County_ IssuArice FEE ; ordinances and.State laivs.,relating,to.buildini.construction, and hereby authorize representatives'of-this County to enter roTnL FEE upon the'ab e_-menti ned property'f'r inspection purposes. SEE REVERSE FOR EXPLANATORY_LANGUAGE , nature of Permittee, Date C kEibzs,COMPENSATIONDECLARATION Ji44- CE-875 (2-80) MISCELLANEOUS APPLICATION I hereby{affirm 't¢at'I have certificate of consent to self COUNTY OF LOS ANGERS BUILDING AND SAFETY DIVISION insdre, or Ak;Ltilicate of Workea rs'Compensation Insurance,or a certified copy thereof•(Sec.3800,Lab:C.)- PLICANT TO FILL IN BILDING FOR AP Policy No. Company ADUDRESS V ❑� Certified copy is hereby furnished.. ApDILDING REss �L LOCALITY X14 126L4- ❑ Certified copy is filed with the-county building inspection NEAREST department. LO LITY CROSS ST. Date Applicant EARL T DISTRICT NO. GR P TYPE PRO ESSED BY CROSS ST. �� '�' ! l1�4 - 5, 09 CONST, e CERTIFIC_ATE'OF EXEMPTION FROM WORKERS' LEGAL o v COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK JMAP it HIGHWAY } • '. NO. ' (CIRCLE) STATE MAJOR SEJOND LOCAL d NO. OF BLDGS. .(This section need not- be completed'if-the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS ' O by ihe.permit,`is for`one"•hundred dollars-.($100) or less.) 'I` USE OF SIZEi OF LOT EX TING BLDG. _ I certify-that-in the performance of the work for which this' Q permit is issued, I shall not employ any, person in any manner OWNERIfA F- so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP W J _ - _ , , 1 AD RESS Date Applicant NOTICE TO APPLICANT: 'If,•aftei making this'Certificate of cIT rJoL OCCUPANT LOAD z Exemption, you should become subject to.:the. Workers' APPLI ATION FOR _ EXIT HARDWARE Compensation provisions.of the Labor Code, you"must forth- with comply with such provlslbns or this permit shall be TRAILER USE -GEOLOGY INSPECTION deemed revoked. ❑ NO Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ , I hereby affirm that:I am licensed under provisions of Chapter SAFETY PERMIT-V (LIST ITEMS'BELOW) NO. OF EXITS 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full-force and PARKING effect. SPACES REq'D O PROVIDED D License-Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE;• O ' �. FROM:, -,TO, I am exempt from the licensing"requirements as'l am a ` licensed architect or a registered professional engineer I SIZE OF NO. OF INSPECTOR'S acting 'in my professional capacity (Section 7051, Bus- EXISTING BLDG; STORIES SI NATURE iness and Professions Code). FINAL APPROVAL RESENT USE OF BUILDINGAN Lic.or Reg,No. Date v HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE —41 9'(�7, /,A I hereby affirm that: I am exempt from the Contractor's '• •'• • 88 •License Law for the following reason (Section:7031.5,'Busi- ness and Professions Code): NO.PARKING SPACES PROVIDEDN .I, as owner of the property, will do the work and the ! • • ••o ••• 2 structure is riot 'intended or offered for sale(Section v 0 5 O 8—8 5 7044, Business and Professions Code). PosED usE of BUILDING CONSTRUCTION LENDING AGENCY - I hereby affirm that there,is a construction lending agency for' the• perfor'mance`of the 'work'for w]iich this permit is issued(Se c..3097,Civ.C.). Lender's Name PROPOSED MAX. OCC., Lender's Address 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 Y ordinances and State laws relating to building construction, D TOTAL FEE a ereby utho 'ze f this County to enter up n e ab ve- sp tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �v ` V Signature of Permittee, Date Wd: KERS'COMPENSATION DECLARATION i ..76M444. CE,8752-80) I SC E L LA N E O U S A;P P L I C A T I O N I r 'he°�,.eby,''affirm that I have a' certificate'ofconsent-to self. ( .'COUNTY:OF--LOS ANGELES '-'BUILDING AND SAFETY DIVISION insure, or a certificate of Workers',Compensation Insurance,or; a•cei'tified copy thereof(Sec. 3800;Lab. BUILDING /' Policy No. Company FOR `APP,LICANTTO.FILL INi A1111INDDRES .i (p' Jz—, c' ' Certified copy'is hereby.fuO inished. UILDING LCALITY 4r i•i:❑, op ..,, - A DRESS •/'�r��,/ - Certified copy is,filed with the county'building'inspection''. NEAREST ' .f t° »r• d64epartment. ,^i LO ALITY, aA / f l- /d/�. /.. D+• CROSS ST._ n ` Date :'Applicanf' " EAREST ,v( L�� i (�'(� L DISTLC T•N G OUP' TY PROC SED - - CROSS ST .G�` ST. 1 �-• CERTIFICATE OF EXEMPTIQN FROM WORKERS' LEGAL JJ - DESCRIPTION.• LOT NO. BLOCK Mwp.,` - HIGHWAY ' COMPENSATION INSURANCE STATE MAJOR'S EC ND LOCAL• , NO.. (CIRCLE) - NO.,,OF'BLDGS:� O (This section .need not be.,completed'•if the work involved TRACT NOW.,ON LOT, USE ZONE SPE CIAL'CONDITIONS ,by the permit:is for .one hundred dollars'($100)';or less.) usE.oF ' ;'r ,++/^�1�/.•f, U SIZE OF LOT EXISTING'BLDG. , r,,!•`'� - �_' I certify that in'the performance of.the work`for.which this., .permit is-issued;I shall not employ.'any person in any mannei owrieR�h 'so-as to-become sub�ect•,to:the Workers;'Compensation Laws. A�� V�4/HH(////JJJJ/a/J E, -, 'OCCUPANCY GROUP, w Y' r • CL ADDRESS•{'{ 4 / J 'O �� K Date " APPlicaric w ;Z 'I/'l�C' CR."• rE x OCCUPANT LOAD NOTICE:TO APPLICANT. If, after,making this,Certificate of I,rr i !7 O ri Exemption,;;you_'should 'become subject to the 'Worker's' APPLICATION-FOR EXIT'HARDWARE: - Compensation provisions of.the:Labor C'o'de"a you must'forth- with comply with such piovtsioris or--this. permit shall-be TRAILER-USE GEOLOGY INSPECTION • - �r.. _ ❑" No Spec. Knowl. 0' deemed revoked: .•` PaniC•Devices ❑ LICENSED CONTRACTORS DECLP RATION- ' OCCUPANCY INSPECTION = y, „ I hereby affirm'that lam licensed under provisions of Chapter SAFETY PERMIT q (LIST.ITE MS BELOW) 9 (commencing,with Section 7000) ofcDivision 3 of the Busl- NO: OF'EXITS �¢ ness and Professions Code, and.my license`is.in full force and effect. _`-I SPACESG REO'D D PROVIDED, D License Number Lic..Class� LIMITED TIME USE Contra Ct OC Date DATE DATE T O: El''I am exempt from"the licensing.requirements assI am'a licensed architect- oi'a registered•professional engineer SIZE OF . NO. OF" - r -INSPECTOR'S acting IR my;professions l capacity (Section 705I,•BUs-., EXISTING,_BLDG. STORIES SI NATURE mess and Professions�Code). FINAL APPROVAL ESENT USE OF BUILDING � , Lic.or•Reg.No. Date lie • . . Q7 / G- HOMEOWNER-BUILDER DECLARATION NO. O AND USE BUILDINGS - - _ y-}. ON LOT,AND USE , � I .hereby affirm,that- I am exempt-from the Contractor's- License Law for,the following reason . tion-7031.5, Busi- -,Gess and Professions Code): NO. PARKING— SPACES PROVIDED 0 1,' as,owner of the property, will.do the'work.and,the . structure is not intended or offered for sale (Section 7044;;'Business and Professions Code). _F p pOSED.USE'OF'BUILDING CONSTRUCTION LENDING AGENCY //__ ,y; I hereby affirm that there,is a construction'leiidln_g agency 1, s i'L� for the performance of the work- wJiich"'this,permit is, 1 �. 0'4,0 4 r 8 6 issued(Sec. 3097„Civ.C.): Lender's Name PROPOSED MAX.,,OCC. + '- Lender's Address PERMITTEE I ceitify,that I-have read this application and''statej that the aboveinformation,is correct. I agree to comply witli all County Is Fee --- ,ordinances' and State laws relating,to building,Construction, TOTAL FEE N and^hereby authorize representatives of this County to enter ' s upon he above-mentione roperty for inspectio purposes. SEE'REVERSE FOR EXPLANATOR,Y•LANGUAGE Signature of Permittee Da et - WORKERS'COMPENSATION DECLARATION 768444_ - - CE 875(11-84) MISCELLANEOUS APPLICATION •- I hereby affirm that I 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 the eo (Sec. 3800,Lab.Q. Policy No. 0 DZftompany n�- T.:IC.. kt�,A FOR APPLICANT TO FILL IN BUILDING �-' ADDRESS Certified copy is hereby furnished. BUILDING l� D( r LOCALITY XX ADDRESS J 0 Certified copy is filed with the county building inspection LOCALITYNEAREST depart ent. }�: TS T CROSS ST. Date Z Applicant NEAREST DISTRIC 0. GROUP CONST. R CE SED BY CROSS 3T. OI/� ITYPE CER IFIC TE OF EXEMPTIO ROM KERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY HD. (CIRCLE) STATE MAJOR SECOND LOCAL - 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 SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manne},X OWNER of building '' 1 C-13 so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP _ o ADDRESS r Date Applicant ILL! NOTICE TO APPLICANT: If, after making this Certificate of CITY No� OCCUPANT LOAD 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 or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 an X effect. Name of business PARKINAG REQ'D PROVIDED I " _y CES ..JJ License Number SP Lic. Class s �� i91� LIMITED TIME USE Contractor Date DATE DATE El I am exempt from the licensing requirements as I am a FROM: INSPECTOR'S licensed architect or a registered professional engineer SIZE OF N I OF "NATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES inessand Professions Code). FINAL APPROVAL �/ A Lic.or Reg.No. Date PRESENT USE OF BUILDING / _( 61 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS U ON LOT ANDAII _USE O 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 0 1, 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.). v II =- Lender's Name - •-�' °" PROPOSED MAX. OCC. _ Lender's Address PERMIT FEE I certify that I have read this application and state that the L M above information is correct. I agree to comply with all County ISSUANCE FEE t't ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25 -00 rl upon the ove-mentioned property for inspection pose . SEE REVERSE FOR EXPLANATORY LANGUAGE ,_rt XX XX 172 J r ignature o Permittee WORKERS' COMPENSATION DECLARATION z000s DPw'2/90 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING AND SAFETY DIVISION _�r .,!insure, or a certificate of Workers'Compensation Insurance, or ll a certified copy thereof (S66. 3800, Lab:Q ' Policy'No. Company FOR APPLICANT TO FILL IN BUILDING _ BLJILDING ADDRESStn1 ADDRESS Certified copy,is hereby;furnished. Ip E �{} M1Otp, LOCALITY Certified copy is filed with the county building inspection CITY ZIP /�1-1�0 de artment 11 NEAREST ' p CROSS ST. Date Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CONST. CERTIFICATE OF EXEMPTION FROM WORKERS, TRACT BLOCK LOT NO. 0 COMPENSATION INSURANCE MAP HIGHWAY V • ' No ` (CIRCLE) STATE MAJOR SECOND LOCAL (This Section need not_be completed if the work involved• ASSESSOR MAP 8OOK PAGE PARCEL I by the permit is for one hundred dollars ($100) or less. USE ZONE SPECIAL CONDITIONS }Q I certify that in the performance of the work for which thisref-T�lhlb LMneE. i��-�J� �� ,No ��b t,) 'Permit is issued. I shall not employ any person in any manner u1 so as to become subject to the Workers' ompensation Caws. l?aiS�RrroD�� $L OCCUPANCY GROUP Date '� Applicant CITY 1 ZIP NOTICE-TO APPLICANT- lf.' after ma mg this Certificate of Exemption, you should become subject to the Workers' OCCUPANT LOAD Compensation provisions of the Labor Code,you must forthwith APPLICATION FOR EXIT HARDWARE. comply with such provisions or this permit shall be deemed TRAILER USE[:] GEOLOGY INSPECTION❑ NO Spec.Know] ❑ revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[1 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 Business game o us Bess NO OF EXITS and Professions Code,and my license is in full force and effect. PARKING• REO'D 1 I PROVIDED License Number Lic. Class -1r�.L� I SPACES LLJJ 1 Contractor Date llN�/ LIMITED TIME USE ❑ I am exempt from the licensing requirements as I am aDATE DATE licensed architect or a registered professional engineer _ FROM: To: acting in my professional capacity (Section 7051,Business SIZE OF NO.OF INSPECTOR'S and Professions Code). - EXISTING BLDG. STORIES SIGNATURE. LIC. or Reg. NO. - Date PRESENT USE OF BUILDING FINAL APPROVAL J62L4L6 31 71 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, Business and Professions Code): NO.PARKING SPACES PROVIDED ❑ I, as owner of the property, will do the work andl'the O��CG structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING Business and Professions Code). CONSTRUCTION LENDING AGENCY I-herebyaffirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, CIV.C.). PROPOSED MAX OCG Lender's Name APPLI-ANT( ) )F', 061 Lender's Address AqgESttA Q,� n I certify that I have read this application and state that the T-W,/ u� m Li, �a ci11to above information is correct I agree to comply with all County PERMIT FEE _ordinances and State laws relat- to building construction,and hereby&hreese tativs of this County to enter upon ISSUANCE FEE the abp96pertJ r inspection purposes. 1 TOTAL FEE I t R 4-�4 SEE REVERSE FOR EXPLANATORY LANGUAGE Slenature of P Inittee Date