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Home My Public Portal About9044 LAS TUNAS DR_Miscellaneous__ WORKFItS'COMPENSATION DECLARATION CE 8754,11.84, MISCELLANEOUS APPLICATION I 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.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING D4 ADDRESS Certified co is hereby furnished. BUILDING O � Z,4<37Ud�9�� bA copy y ADDRESS I LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. l�M�j C P�Y CA `j 17 CROSS ST. Date Applicant NEAREST j�p �\�.r7w r`I D LV IIS DIST T G OUP CONST. PR CESSED BY CROSS ST. KV C.tT I? Y� py5j �TY PE CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HGHW AV No. "(CIRC.EI STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This sectio need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPEC L CONDITIONS by the per mi is for one hundred dollars ($100) or less.) . - USE OF SIZE OF LOT $ n EXISTING BLDG. I Certify that in e performance of the work for which this 40o permit is issued, I s all not employ any person in any manner OWNER D/-11V FI�hVOUE� so as to become sub ct to the Workers' Compensation Laws. MAIL y�]/ /�/j _J9 ( A OCCUPANCY GROUP o ADDR ES-X /v`(-`f'� (�'v �• M, ~ Date Ap icant _ UJ NOTICE TO APPLICAN : If, after making this Certificate of clr ?�ii/pL La 7Y NOI F1� 310 SOCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions o the Labor Code, you must forth with comply with such p visions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRA ORS DECLARATION OCCUPANCY INSPECTION Panic Devices 1 hereby affirm that I am hcen d under provisions of Chapter SAFETY PERMIT ❑ LIST ITEMS BELOW) 9 (commencing with Section 70 0) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and license is in full force and effect. •f_ a PARKING _ SPACES REQ'D D PROVIDED License Number L . Class Al AILSA"1�r b 'f—A C e A L. 5 A L b LIMITED TIME USE Contractor Da a DATE DATE 0 I am exempt from the licensin requirements as I am a licensed architect or a register d professional engineer SIZE OF NO. OF FROM: To: INSPECTOR acting in my professional capa ity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). ,'�S J.i._ FINAL APPROVAL o` V PRESENT USE OF BUILDING 1/ Lie.or Reg.No. Date aa HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 3— FEE ON LOT AND USE I hereby affirm that I am exempt from the Contractor's iI- ,;_-;;- License Law for the following reason (Section 7031.5, Busi -'L°�! = ti _/ =1) 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 �I 7044,Business and Professions Code). r PROPOSED USE of BUILDING CONSTRUCTION LENDING AGENCY i I hereby affirm that there is a construction lending agency lv,+iLS £1 -F,4cuA „ - 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 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 TOTAL. FEE upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature�ermittee Date WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I heredy affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insure, or acertificate of Workers'Compensation Insurance,or , a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING -, I , ADDRESS ❑ Certified copy is hereby furnished 440 BUILDING 4a, - rV LOCALITY ADDRESS ❑ Certified copy Is filed with the county building inspection NEAREST department Lo ALITY CROSS ST t Date ApplicantS EARET DIST T G UP TYPE PROC BY ED CROSS ST Q� O ONS , CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY _ No (CIRCLE) STATE MAJOR SECO LOCAL a NO OF BLDGS. O (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V. V by the permit is for one hundred dollars ($100) or less.) USE OF SIZ OF LOT EXISTING BLDG - O I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner WNER 4 1-- so so as to become subject to the Workers' Compensation Laws AIL �O `� OCCUPANCY GROUP W ADDRESS y/!V I-oS U) Date Applicant Z NOTICE TO APPLICANT If;after making this Certificate of CITY do NoL OCCUPANT LOAD Exemption, you should become subject to the Workers' APP CATION 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) 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 PROVIDED License Number Lic Class ' LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM TO INSPECTOR'S licensed architect or a registered professional engineer SIZE OF NO. OF acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES S)GNATURE mess and Professions Code). ESENT USE OF BUILDING FINAL APPROVAL 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. PARKING SPACES PROVIDED- _ ❑ I, as owner of the property, will do the work and the # o,•,o e,$8 structure Is not Intended or offered for sale (Section 7044, Business and Professions Code) i;WOPOSED USE OF BUILDING 0 . 0 0,0 0 0 2 CONSTRUCTION LENDING AGENCY ' I hereby affirm that there Is a construction lending agency GC' -0 6.0 5,�-8 5 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 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, TOTAL FEE �QD and hereb autho�yesentatives of this County to enter upon th a ove-mproperty for inspection urp ses SEE REVERSE FOR EXPLANATORY LANGUAGE 17 Signature o Permittee Dat WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS A P P L I C A T I O N I 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.) IN ILD BUG B ' Policy No. Company FOR APPLICANT TO FILL IN AILDIN ❑ ss Certified copy is hereby furnishedBUILDING - LOCALITY ADDRESS ❑ Certified copy is filed with the county building Inspection i NEAREST department LOCALITY CROSS ST 'Date ApplicantEAREST DISTRICT NO. OUP TYPE PROCESSED BY CRO35 ST. Q CONST CE RTIFICATE,OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION LOT NOBLOCK MAp HlcHwwY d COMPENSATION INSURANCE No [yQ (CIRCLE) STATE MAJOR SECOND LOCAL t b d i (This section neenot completed if the work involved NO OF BLDGS. p l P TRACT � NOW ON LOT USE ZONE SPECIAL CONDITIONS U by the permit is for one hundred dollars ($100) or less.) USE OF BLDG cc I certify that in the performance of the work for which this perm)t is issued, I shall not employ any person in any manner S ZE OF LOT EXISTING O OWNER (, so as to become subject to the Workers' Compensation Laws AIL OCCUPANCY GROUP LU ADDRESS Z117 -2— �u�� ^J C " Date Applicant Z OCCUPANT LOAD TEL //_+1 NOTICE TO APPLICANT If, after making this Certificate of Iry rvD .Exemption, you should become subject to the WorkersAPPL ATION 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 INSPECTIONCl 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) NO OF EXITS 9 ("ommencing with Section 7000) of Division 3 of the Busi- nesw and Professions Code, and my license is in full force and, PARKING effect. - SPACES REQ'D O PROVIDED O • I Licfnse Number Lic Class LIMITED TIME USE Contractor Date DATE DATE ❑ TO FROM I am exempt from the licensing requirements as I am a INSPECTOR'S licensed architect or a registered professional erigmeer SIZE OF NO OF acting in my professional capacity (Section 7051,-BUS- EXISTING BLDG. STORIES ® SIGNATURE iness and ProfOF BUILDING �essions Code). o ,/►`,_ FINAL APPROVAL ESENT USE r v 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 c 8 017 2.A License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING {{ 8 8 7T o 10 0 o 8 8 SPACES PROVIDED � , ❑ I, as owner of the property, will do the work and the N- structure is not Intended or offered for sale (Section o ol0 0 0`0.0 7044, Business and Professions Code). J. ROPosED USE of BUILDING O 11109:-84 .CONSTRUCTION LENDING AGENCY I hereby affirm that-there is a construction lending agency for the performanceof the work for which this permit is Issued (Sec 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 corret. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter upon the above-mentioned property for Inspect) n purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signatu of Permittee Date I�i✓ORKN.RS'COMPENSATION DECLARATION 76M444 Glez-&M I- E L LA C L I C AT I O N v' CE 876 (11-84) insure, a cert 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 FILL IN BUILDING " ADDRESS Certified copy is hereby furnished BUILDING A ��ha ADDRESS LOCALITY ❑ Certified copy is filed with the county building inspection LOCALITY \ C NEAREST department. Q Vh \ ` CROSS ST Date Applicant NEARESTCROSS ST. 0,_C5 Se .X CONS DISTRICT NO. GROUP JTYPE OC SSED BY � -`" -y- CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP ICHw AY NOOF BLDGS No. �+ / CIR CLE) STATE MAJOR SECOND LOCAL (This Section need not be completed if the work'involved TRACT NO.W 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 SIZE of Lor EXISTING BLDG. O permit is issued, I shall not employ any person in any manner "OWN EFf- C3� V� C O Y\ ( ver so as to become subject to the Workers' Compensation Laws. AIL r,1 ` OCCUPANCY GROUPeM a ADDRESS i 1 .y �ti�C-, r- Date ApplicantTE NOTICE TO APPLICANT If, after making this Certificate of i TY �2v� �� )►. NOL 2 , \ S OCCUPANT LOAD Exemption, you should become subject to the Workers' gppLl ATION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth with comply with such provisions or this permit shall be TRAILER USEGEOLOGY 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 ❑ (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 SPACES effect. PARKING REQ'D I PROVIDED License Number Lie. 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 OF No of INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES D SIGNATURE iness and Professions Code) FINAL APPROVAL �J 'v �C`�� //✓ Lie.or Reg No. Date RESENT USE OF BUILDING (/ 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 �. \ 5 6 7,0 A I hereby affirm that there is a construction lending agencyQ� `�� r �N # 0 0 0 0 88 for the performance of the work for which this permit is issued(Sec. 3097,Civ C.). CkINcA 5k C � `(� 0 0 e 0 0 0 0 Lender's Name 1 0�, 1 6=8 6 PROPOSED MAX. OCC. 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 ISSUANCE FEE ordinance nd State laws relating to building construction, and he authorize represerItatives of this County to enter TOTAL FEE upon the ove entio pr erty for inspection purposes. �l0 SEE REVERSE FOR EXPLANATORY LANGUAGE I/ Signiture of Per '-t a ate WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 I 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 Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS FiCertified copy is hereby furnished. BUILDING �� /1� ///�� ADDRESS !f LOCALITYrEM {✓J ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST PIC department. CROSS ST. Date Applicant NEAREST // /� p O DI RJJJC G TYPE P:MSY CROSS ST. S i—,4 � �`. {� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SE CO NO. F SLOGS. N LOCAL (This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF ' •� I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.�0 o ox o permit is issued, I shall not employ any person in any manner OWNER0. so as to become subject to the Workers' Compensation Laws. MAIL ^ /l 11 _ /7j$CCUPANCY GROUP o ADDRESS Y Z ' +� CJ C.:)Date Applicant NOTICE TO APPLICANT• If, after making this Certificate of -'-YlNO /� O _� OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code,you must forth- E]with comply with such provisions or this permit shall be TRAILER USE El GEOLOGY INSPECTION No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY NAK Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PER IT ❑ (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. NYi �U PARKING _ �^ /��,/ SPACES REq'D � PROVIDED License Number Lic. Class r W�✓ - LIMITED TIME USE Contractor Date DATE GATE F1 I am exempt from the licensing requirements as I am a FROM TD licensed architect or a registered professional engineer SIZE OF NO OF INSPECT S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES sIGNAT E iness and Professions Code). p r FINAL APPROVAL D PRESENT USE OF BUILDING C' 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 usi e � ness and Professions Code)• NO. PARKING / 19i� I, as owner of the property, will do the work and the SPACES PROVIDED tJti(7 1 A structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDIN I hereby affirm that there is a construction lending agencyI 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 C-QC5 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 TOTAL. FEE 'upon the above-mentioned prope y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date f 30/?Q WORKERS'COMPENSATION DECLARATION M I SC E L LiA REO U S A P P L I C A T I O N I hereby affirm CE 875 - CE 875(1 I-84)affirm that I have a certificate of consent to self insure; or a certificate of workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILmING AND SAFETY DIVISION a certified copy 1 hereof(Sec 3800,Lab.C.) • Policy No. - Company FOR APPLICANT TO FI LL IN ADDRESS 7-7 O Certified copy is hereby furnished. BUILDING04 ^ LOCALITY ADDRESS 7 ❑ Certified copy is filed with the county building inspection department LOCALITY CROSS sT Date Applicant NEAREST GI-DI Jeo DISTRICT NOUP TYPE CESSED BY CROSS ST. O Q CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o COMPENSATION INSURANCE DESCRIPTION Lor NO, BLOCK MAP HIGHWAY NOOF SLOGS. NO (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NO.W 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 SIZE OF LOT EXISTING BLDG. permit is issued, I shall not employ an o p p y y person in any manner OWNER _ - C� so as to become subject to the Workers' Compensation Laws MAIL 1 (�— J�- rj, OCCUPANCY GROUP ADDRES I�+�C 6 O O Date Applicant nT E L. w NOTICE TO APPLICANT If, after making this Certificate of CITY 1 lam. t`��v No. �� zyS j�1� OCCUPANT LOAD O rn 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. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E] 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 �//y _� effect. v, PARKING PARKING SPACES REQ'D D PROVIDED D License Number Lic. Class -t) LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE mess and Professions Code). FINAL APPROVAL _ PRESENT USE OF BUILDING O 29! Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS 13 FEE ON LOT AND USE p��• J I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness usi ness and Professions Code): NO PARKING SPACES PROVIDED El I, as owner of the property, will do the work and the %f!_.i 1 Prl 4.5 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 ' I certify that I have read this application and state that the PERMIT FEE above information rs Corr t I afire to mply with all County ISSUANCE FEE ordinances and State 1 reo building construction, and hereby autho ize r es es of this County to enter TOTAL FEE ®� uponth >n ntio erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'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 certYled copy thereof(Sec. 3800,Lab.C) Pol;cyNQ ' Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING Q�r ADDRESS '7" y �t� 'r�N,%A/ Dk LOCALITY !ten J 10, 0 Certified copy is filed with the county building inspection LOCALITY I NEAREST department. c • CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE CESSED BY CROSS ST. 5. r21 a CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY IVO (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 I certify 'that in the performance of the work for which this slzE of LOT EXISTING BLDG. o permit is issued, I shall not employ any person in any mannerOWNER so as to become subject to the Workers' Compensation Laws. Of- Gt 1 D �� OCCUPANCY GROUP MAIL ;LDDR SS Date Applicantp LWJ NOTICE TO APPLICANT• If, after making this Certificate of CITY 1 _ NOI. �0� 5=CTq✓ 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 USEGEOLOGY INSPECTION ❑ ❑ El 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 andR U SI I effect. Q 4 S a�+'s PARKING REQ*D PROVIDED LL�� License Number Lia Class • �C'�1 AL 5-41-o5-41-o N SPACES LIMITED TIME USE Contractor Date DATE DATE FROM 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 SIGN TURF mess and Professions Code) FINAL APPROVAL L'�9 Lnc.or Reg.No. Date PRESENT USE OF BUILDING HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 0 B JII� ON LOT AND USE b I hereby affirm that I am exempt from the Contractor's .r�;V{t License Law for the following reason (Section 7031.5, Busi- `' 1 1�Ei:I ness and Professions Code): NO. PARKING IT`tic i I, as owner of the property, will do the work and the SPACES PROVIDED _ -?5 00 structure is not intended or offered for sale (Section ;07 HL ....--_s 7044,Business and Professions Code). Iit ,;� ROPOSED USE OF BUILDING 'HECK CONSTRUCTION LENDING AGENCY \ CAME I= 6); I hereby affirm that there is a construction lending agency MAI L � �`S n w for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC, Art; 'C s Art Lender's Address - /, f�� "�'= I certify that I have read this application and state that the PERMIT FEE pv 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 (gyp upon the above-mentioned propertyfo spectnon purposes t cv `f SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ture of Permittee ate