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Home My Public Portal About8802-04 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 7E 875 (11-84J CE 675 MISCELLANEOUS APPLICATION n I hereby affirm that'I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certi�icate of Workers'Compensation Insurance,of a certified copy thereof(Sec. 3800,Lab.C.). - Policy N6 Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. L/ BUILDING UD ADDRESS ERE DSS 8802 E, LAS TUNAS DR. P LOCALITY �' Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS sr. Date-Applicant - NEAREST DI/i.�IC �. G U PE P CE BY CROSS ST. r\ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL r COMPENSATION INSURANCE 'DESCRIPr eLocK Ia RwA Ory LOT NO. ICI LE) STATE MAIOR ECO 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 (5100) or less.) USE OF SIZE OF LOT EXISTING BLDG. Y 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 MurraySeidner so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP• m XMAI AD RESS 4500 N. Rosemead Blvd. Date Applicant I-„ TEL' _ OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY Rosemead, No. 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 provisions oI this permit shall be TRAILER USEGEOLOGY INSPECTION EJdeemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices 1 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. M( PARKING SPACES REO.O PROVIDED License Number Lic. Class NORMAN COLLAR INSURANCE AGENCY LIMITED TIME USE Contractor Date ooTE DATE ❑ I am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer SIZE OF NO. OF sP ECTOR•S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES I NATURE iness and Professions Code). INSURANCE AGENCY FINAL APPROVAL � PRESENT USE OF BUILDING Lic.or Reg. No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 1 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- 11000-1-213131 51 3/c!) ness and Professions Code): NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED a f� I p.ep fl 7. structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY 6C PROPOSED USE of Buunmc INS I hereby affirm that there is a construction lending agency G v for the performance of the work for which this permit is _ issued(Sec. 3097,Civ.Q. r� O Lender's Name /� 1rf'• ' PROPOSED MAX.'OCC. J Lender's Address Civ PERMIT FEEIT,Vv 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 he;0y authorize representatives of this County to enter TOTAL FEE u on ijff vesp -mentioned property for inec 'o urpo�SGs. ' SEE REVERSE FOR EXPLANATORY LANGUAGE . �na ebf ermittee Date WORKERS'COMPENSATION DECLARATION a CE875 111-641 MISCELLANEOUS APPLICATION {� CE 87LJ thereby affirm that I 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.). Policy No. Company FOR APPLICANT TO FI LL IN BUILDING „r ❑ ` ADDRESS 'TJ Certified copy is hereby furnished. v B IDRLoEss 1dS�1 1Nc AD (X)!,& 1 nr I �ey+TJ LOCATY PL L-1^ Certified copy is filed with the county building inspection �� p�{ NEAREST department. LocwurY ' ;k W CIN L.l� I I CROSS ST. Date Applicant NEAREST �114.F,�1 DISTRICT GDBOOL TYPEBY CROSS ST. t/ C� r[�V //'✓/� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS" LEGAL l ,r`, COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP IC.wA NOOF ' (c LEI STATE MAIOR GOND LOCAL . IS (This section need not be completed If me work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) USE OF I certify that in the performance of the work for which this� SIZE of LOT pp ��,! `tr11 EXISTING BLDG. o permit is issued, 1 shall not employ any person in any manner v OWNER MUQCAI I StEyaGly '' so as to become subject to the Workers' Compensation Laws. MAIL pl l� \\ n %�� OCCUPANCY GROUP o 'X wDDw Ess �UV 'J ' ILII pC I"I,C Date Applicant a6 NOTICE TO APPLICANT: If, after making this Certificate of CITY noL g 6OCCUPANT LOAD o_ Exemption, you should become subject to me 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 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bust SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO, OF EXITS ness and Professions Code, and my license is in full force and1, 1�, /IS' effect. V� V�Yl2' Y // PARKING REDO [ PROVIDED SPACES License Number Lia Class LA� D2 LIMITED TIME USE Contractor Date ��II pp �,� n �f D•Te CDATE{TM. f L 1 am exempt from the licensing requirements as I am a N---' C _`) / licensed architect or a registered professional engineer SIZE OF No. OF INSPECTOR'S . acting in my professional capacity (Section 7051, Bus- EXISTING BLoc. ' sroRlEs + SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date ��-- it VTI Ia e/u HOME OWNER-BUILDER DECLARATION No.of EXISTING lLmrvcs ' ON LOT AND USE i .... ........ ..... ..._.._..._. . .. __. .... ...... 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- 00030-0001 5/31/917 ness and Professions Code): NO.PARKING F11, as owner of the property, will do the work and the SPACES PROVIDED 111`5 1 AM 9:at structure is not intended or offered for sale (Section L - 7044,Business and Professions Code). pT/,. CONSTRUCTION LENDING, AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency V OK I u U for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. �1 Lender's Address PERMIT FEE �O 1 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 an thorap,representatives of this County to enter TOTAL FEE 5 upb a above-menti ed property for inspection pu pas ' $ SEE REVERSE FOR EXPLANATORY LANGUAGE 'gnature of Pe Ila tee date WORKERS'COMPENSATION DECLARATION _ 7510444 MISCELLANEOUS APPLICATION {� LJ I hereby affirm CE 875 (11-84)that I have a certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,ox a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN - BUILDING A D.RE55 DaO iL/f`i1.O �G� ❑ Certified copy is hereby furnished. BUILDING O WA y�.r - ADORESs f6P- LOCALITY ❑ Certified copy is filed with the county budding inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST {(l/1 /J. DISTRICT NO. GR P TYPE CESSEO BV CROSS.ST. tJ,r(�`J T� - `OO �TCONST YIE CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a '�� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK XI, HIGRWAY . - (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed If the WOIk involved TRACT NOW ON LOT USE ¢ONE SPECIALCONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. �y I certify that in the performance of the work for which this DRIP `` I 111//J o permit is issued, I shall not employ any person in any manner wNER DRIP tLi i Idi so as to become subject to the Workers' Compensation Laws. /,(— A, �� ' OCCUPANCY GROUP Date Applicant MV DR Ess T1j OD N, p`^�'�,^IA E3 TEL. ,f 2dQ1'- l3� NOTICE TO APPLICANT: If, after making this Certificate of crcr No. L OCCUPANT LOAD O_ 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 provisions OI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ElPanic 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 yq/1 q f(� p\� ,I�.( effect. Ileo O ✓`{Si(I i!fs ' PARKING1^I /.�pZ �� SPACES REO,D � PROVIV ED � I License Number Lic. Class W&J 7`� A�6 'bf)Iv LIMITED TIME USE J Contractor Date DATE oA'. ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF - ry 1. OF IN T acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. sr BRIE. SIGNATURE iness and Professions Code). Date REservT USE of BUILDING FINAL APPRO Lia.or Reg.No. VAL r N07/%-1 Ude YE 7 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 1N C�Ge=t �� ' h I hereby affirm that I am exempt from the ContractorON LOT AND USE 's 00 JI1i, - License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING tlti1i17—ij (�j J ❑ I, as owner of the property, will the work and the ----. _ 1 structure is not intended or offered 9 2 SPACES PROVIDED 4i d fox sale (Section � i Fhi 374 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency - J N-�fr, for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). ' Lenders Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that 1 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 au a xesentatives of this County to enter TOTAL FEEA6. uv upon the at v n ' e peaty for inspection pu po s SEE REVERSE FOR EXPLANATORY LANGUAGE _O e o V`ittee D e WORKERS'-COMPENSATION DECLARATIONa MISCELLANEOUS APPLICATION CE 87675 (l 1-841 I he 'CE hereby affirm that I 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.). Policy No. Company FOR APP LICANT TO F I LL I N BUILDING ADDRESS OO / G ❑ Certified copy is hereby furnished. AUIL.INGADDRESS LO CA urY ❑ Certified copy is filed with the county building inspection o<A urY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICTN. GR�'UP TYPE PlR/OJCESSED BY CROs . $T. V D (/ L"� CONST. , / L�a'� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O .6J- V COMPENSATION INSURANCE DESCRIPTION LOT rvo. BLOCK ID�wA NOOF EI . (CIRCLE) STATE MAJOR SECOND LOCAL . (This section need not be completed If the wo[k involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars (^$100) or less.) US of SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this OOO o permit is issued, I shall not employ any person in any manner OWNER #IV so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS Ox 5 V Date Applicant E NOTICE TO APPLICANT: If, after making this Certificate of clrY G � rn�ioL.. ff- �)( 5 OCCUPANT LOAD � 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 provisions Or this permit shall be ' TRAILER USE GEOLOGY INSPECTION ❑ No Spec. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E_ Panic Devices ❑ 1 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 REG'D = PROVIDED 1 SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OFNo. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. sroRlEs SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lie.or Reg.No. Date -zo-f N e a HOME OWNER-BUILDER DECLARATION NO. OF E UST Ic UILDINGS FE ON LOT AND E V 1/ [ hereby affirm that I am exempt from the Contractor's License Law for the following-reason (Section 7031.5, Busi- '/I 011130-1]I]01 ness and Professions Code): NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED e('11_, f AM 9:57F1 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 1 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 w 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 an State 1 vs relating to building construction, and hereby utl or rPresentatives of this County to enter TOTAL FEE �ugan the o top rt for inspection purposes. �ir� ��_J SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur o Permittee Date I L Y. '-W02KER.5'COMPENSAT[ON DECLARATION CE 875 11 1-64) MISCELLANEOUS APPLICATION , CE 875 r � I hereby affi m that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ,ILII insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BDDR.EG _ .}� BUIL E55 dd -PL(L SLC., QCertified copy is hereby furnished. ulLmrvc e7� rj ) S '/ ZIA1 LOcwurY � - wvvREss OO T LrJ ElCertified copy is filed with the county building inspection LOCALITY �C �I't/��-E C I T NEAREST ' department. CROSS ST. Date Applicant NEAREST �'t� /I DISTRICT NO. GROUP TYPE J CESSEv BY CROSS ST. 5C 16` �O� - �j CONST. // f _` CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No. BLocK IC Rwa (CIRCLE). STATE MAJOR SECOND 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 (SI00) or less.) - , USE OF . SIZE OF LOT EXISTING BLDG. /,� a I certify that in the performance of the work for which this AJ r o permit is issued, 1 shall not employ any person in any manner OWNER Ry S- �,�'YG f v so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP s wo aes *,fad x E:)46,4i) • VD Date Applicant LUL, TEL NO.. _ OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY 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 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- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PA RXING REO'D E= PROVIDED �J SPACES License Number Lic. Class LZ� DL D 9N S �SSO LIMITED TIME USE Contractor Date DATE OATS DI am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer SIZE OF NO. OF I INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES I 51 ATURE iness and Professions Code). FINAL APPROVAL �/ 2'� PRESENT USE OF BUILDING G Lic.or Reg. No. Date IJI tI,I?-tl_lil_i %i.0%'i4 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS J_ _ ON LOT AND USE '(12 } F'ht 21tlii 1 hereby affirm that 1 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.Q. Lender's Name - PROPOSED MAX. OCC. Lender's Address Bn I certify that 1 have read this application and state that the PERMIT FEE above information is correct.I agree to comply with all County ISSUANCE FEE r or ances and State laws relating to building construction, B-O d hereby an horize represen 'ttiv s of this County to enter TOTAL FEE 5 v -mentioned er f r i spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ign, r ermittee Da WORKERS'COMPENSATION DECLARATION 7sMa4aM ISCELLANEOUS APPLICATION CE 875(11-84) 1 hereby affirm that I have a certificate of consent 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.). pp Policy No. Company - FOR APPLICANT TO FI LL IN Boon ss Q Certified copy is hereby furnished. BUILDING (: _ _ ADDRESS ADDRESS LOCALITY Certified copy is filed with the county building inspection LOCALITYf 'I NEAR sr department. f / . Date Applicant NEAREST _ DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. ' I. ' ` CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. STATE MAJOR EE CONO LOCAL _ NO. OFBLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE 5PECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) usE OFCZI - a I certify that in the performance of the work for which this slzE OF Lor EZIsnNyG BLDe. CZI UJ permit is issued, 1 shall not employ any person in any manner OWNER' . ' (' .'s ) '- so as to become subject to the Workers' Compensation Laws. MAIL _L � OCCUPANCY GROUP ADDRESS "Y- %1a f-1 Date .Applicant d L. NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. OCCUPANT LOAD Exemption, you should become subject to the 'Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- El comply with such provisions or this permit shall be TRAILER E)USE GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. - LICENSED CONTRACTORS DECLARATION occu PAN ov-INSPEcnoN ❑ Panic Devices E I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- I NO, of EXITS ness and Professions Code, and my license is in full force and effect. t 1 PARKING SPACES REDID D PROVIDED �. License Number Lie. Class _T" � J LIMITED TIME USE Contractor - Date 5 DAT. I am exempt from the licensing requirements as I am a - _ ATE licensed architect or a registered professional engineer SIZE of NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lie.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. PARKING - I, 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.). Lender's Name PROPOSED MA%. 00C. Lender's Address 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 ISSU ANCE,FEE l ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . Signature of Permittee I Date - J R'01C6ERS'COAIPENSATION DECLARATION 875 I1La41 44 MISCELLANEOUS APPLICATION {� CrCE L1 I uaffirm that 1 have a certificate of consent to see COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, , o or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab.C.). BUILDING — Policy No. Company FOR APPLICANT TO FILL IN o wO ORE55 " ,f C J"Ly�r• /Se-UCg , XX Certified copy is hereby furnished. BUILD D O INc // / _S �J' LOCALITY ems, wR Ess s. ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. A /rr e,• T CROSS ST. Dale Applicant NEAREST OISTRICTDN� 7P TYPE CONSP E59EO BY ICROs, ST. M"LJL-��]'/ CL T. CERTIFICATE OF EXEMPTION FROM WORKERS' DeLEG COMPENSATION INSURANCE sCRIrTwN Lor No. BlocK ,cwww 'C, CA) STATE MAJOR SECOND LOCAL NO. OF BLDGS. NO C (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE 5PECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE or 1 certify that in the performance of the work for which this SITE or Lor EX LISTING BBL^DG. permit is issued, I shall not employ any person in any mannekX OWNER of building %f Sal h 1?)- ® :� m as in become subject to the Workers' Compensation Laws. MAIL1/ p OCCUPANCY GROUP ADORE Y, Date Applicant / ern u NOTICE TO APPLICANT: If, after making this Certificate of CITY C N0. )S' _7�3 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 ❑ deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 1 hereby affirm that 1 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 PARKING P� SPLICES REp'O � PROVIDED License Number Lic. Class 0 L A) C ✓`Dir LIMITED TIME USE Contractor Dale OATS o>TE ElI am exempt from the licensing requirements as I am a ..<M: licensed architect or a registered professional engineer slz E•oP, No. or INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG.`ems/ , �L sroRlEs r SIGNw T'RE iness and Professions Code). _ FINAL APPROVAL .��•7 ,q� Lic.or Reg.No. Date PRESENT USE or BUILDINGV"7 -/�R 8 HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS ON LOT AND U99 ,^ _ I hereby affirm that 1 :un exempt from the Contractor's �1✓ e'4!a_a v�' .5'. License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED ;-It. ii i 1, as owner of the property, will do the work and the )_ —f J(1i1'.: structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSI'RLIC"PION LENDING AG17NCY PROPOSED USE Or 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,Ci CJ Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE 25 . 001 1 certify that 1 ha It this application and state that the above informati is ) rect. 1 agree to comply with all County ISSUANCE FEE ordinances and St a us relating to building construction, and hereby auth 2e epresentatives of this County to enter TOTAL FEE 25 .UO spection on t bove- entioned property for inpurposes. 1 L XSEE REVERSE FOR EXPLANATORY LANGUAGE X XX 15211 nnuure of Permittee Date