The URL can be used to link to this page

Home My Public Portal About9083 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 CE 875(11-84) : N ISCELLAN OUS APPLICATION I hfreby affirm that I have a certificate of consent to self I COUNTY OF LOS ANGELES LD DIVISION . insure, or a certificate of Workers'Compensation Insurance,or �� 6 a certified copy thereof(Sec 3800,Lab.C). lll�� Policy No. Company FOR APPLICANT TO FILL IN BUILDING -�, ADDRESS 1 Certified copy is hereby furnished BADUILDDRENSIGS LOCALITY Certified copy is filed with the county building inspection LOCALITY- NEAREST � y department. CROSS ST. �V L Date, Applicant NEAREST D�t�IC x {111 GROUP TYPE PRO SS BY ,. CROSS ST. fry / ' CONST. - - CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �/t V COMPENSATION INSURANCE DESCRIPTION- LOT NO. BLOCK = NOP 'HIGHWAY (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 n/ a , I certify that in.the performance of the work for which this SIZE OF LOT EXISTING BLDG. ✓✓✓ ��` cccJJJ o permit is issued;I shall not employ any person in any manner OWNER h - so as to become subject to the Workers' Compensation Laws. MAIL L OCCUPANCY GROUP o ADDRESS Date Applicant Q L, NOTICE TO APPLICANT• If, after'makmg.'this Certificate of CITY C No�gID l—'1, OCCUPANT'L'OAD' v�iss Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE z 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. Know]. El deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El - 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. PARKINGREq'D D PROVIDED D • - y - SPACES- License Number Lic. Class LIMITED TIME USE Contractor Date _ DATE ATE I am exempt from the licensing requirements as I.am a licensed architect or a registered professional engineer SIZE OF IND OF N ECTORIG NATURE O EXISTING BLDG. STORIES acting in my professional capacity (Section 7051, Bus- _ .,iness and Professions.Code). FINAL APPRO AL x { ` Lic:or Reg.•No Date PRESENT USE OF BUILDING I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the_Contractor's 10 5/N License Law for the following,reason (Section 7031 5, Busi- ness,and Professions Code): 'NO. PARKING Q 9:44 I, as owner of the property, will do the work and the SPACES PROVIDED l 1+ structure is not intended or offered for sale (Section 7044,Business and Professions Code). 01 i •; PROPOSED USE OF BUILDING 1 CONSTRUCTION LENDING AGENCY I hereby-affirm that there is a construction-lending agency I - for the performance of the work for which this permit is ti ' issued(Sec. 3097,Civ C).' - Lender's Name , I PROPOSED MAX. OCC. a , t i• `- ' , Lender's•Address I certify that I have read this application and state that the PERMIT above information is correct. I agree to comply•with all County ISSUANCE FEE I of minces and State laws relating to building construction, I1 an(i hereby authorize representatives of this County to enter TOTAL FEE 0 ' up he above-mentioned property for inspection purposes { SEE REVERSE FOR EXPLANATORY LANGUAGE q a/ Signature of Permittee ate 'WOR`IeERS'COMPENSATION DECLARATION 76nn444 875 (11-84) M I SC E L LA N E O U S APPLICATION ,CE • 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 ` BUILDING Policy No Company FOR APPLICANT TO FILL IN ppDRE55 Q$ -4..4J d I/ , FiCertified copy is hereby furnished, BUILDINGLAS 1I LOCALITY Y ADDRES V Certified copy is filed with the county building inspection LOCALITY NEAREST department. ceoss ST. S(JL ,(//a Date Applicant NEAREST SULTg /, ~ DISTRICT NO GROUP TYPE PROCESSED BY ' CROSS ST. V 1 Nn - CONST ~ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE '' DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO -('CIRCLE) STATE,MAJOR:SECOND LOCAL ANO. OF BLDGS. - (This section need not be completed,if the Work Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS bthe 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. y O ,permit is issued, I shall not employ'any person in any,mariner OWr E so as to become subject to the Workers' Compensation Laws. �((nn��qq _ OCCUPANCY,GROUPMAIL � AD DR ES �//` Z O Date'_Applicant 'h S t✓ NOTICE TO APPLICANT: If, after male' this Certificate of CITY i j1 TNo�' —'I 3 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'E] 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 E] (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3'of the Busi- `NO. OF EXITS F ness and Professions Code, and my license is in full force and G REQ'D D PROVIDED SPACES effect. PARKIN License Number Lic. Class LIMITED TIME USE Contractor Date - - DATE DATE I am exempt from the licensing requirements as I am a PROM = TO: licensed, architect or a registered professional engineer SIZE OF a�o T NO OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES G ATUR iness and Professions Code). PRESENT USE OF BUILDING I V,ecANj FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS - ON LOT AND USE yiif_itil—� I hereby affirm that I am exempt from the Contractor's _ License Law for the following reason (Section 7031 5, Busi- AN11 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\) DL Q12 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.). O Lender's Name PROPOSED MAX.IOCC. \ 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 ordinances•and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL. FEE n upon the above entioned property for inspection purposes. ld SEE REVERSE FOR-EXPLANATORY LANGUAGE ' Signature of Permittee Date - - I v WORKERS'COMPENSATION DECLARATION 7884444.(11-84) M ISCELLANEOUS�APPLICATION �. 76 1 hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BYIILDING AND SAFETY DIVISION a certified copy thereof(Sec. 3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUIL DIADDRESS �! O NG /�D `? J . Certified copy is hereby furnished. BUILDIIG XX ,ADDRESS DY LOCALITY Certified copy is filed with the county building inspection ,LOCALITY NEAREST V department. CROSS ST. Date Applicant - NEAREST DISTRICT.NO. GRf�UP TYPfi CESSED BY CROSS ST ' yj /� �j( CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL i�f 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 I NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF , ) r SIZE OF LOT EXISTING BLDG. 1 certify that in the performance of the work for which this 0.o permit,is issued, I shall not employ any person in any manneXX .--.Rof building-Z&A ��S so as to become subject to the Workers' Compensation Laws MAIL " /� OCCUPANCY GROUP aD o MAILADD �F Date Applicant w NOTICE TO APPLICANT- If, after making this Certificate of CITY rTvo �) [� OCCUPANT LOAD" O_ 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 I 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 at* (�I effect. Name of business PARKING ) SPA CH9 REQ'D PROVIDED / l.- J License Number Lic. Class LIMITED TIME USE Contractor Date r DATE DATE I am exempt from the licensing requirements as I am a licensed architect or a registered professional.engineer SIZE or NO. OP FROM: To INSPECTORS acting in my professional capacity (Section 7051, }Sus- EXISTING BLDG. STORIES SIGNATURE mess and Professions Code). FINAL APPROVAL Lic.or Reg'No. Date PRESENT USE of BUILDING - 17 O l( i�l:tti�—I:hili _'::• -� HOME OWNER-BUILDER DECLARATION NC. OF EXISTING BUILDINGS- - ON LOT AND USE I hereby affirm that I am exempt from the Contractors F License Law for the following reason (Section 7031.5, Busi- r LIP ness and Professions Code). NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED structure is not iniended or offered for sale (Section 7044,,Business and Professions Code). `S CONSTRUCTION LENDING AGENCY" PRorosfio use of BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is a issued(Sec. 3097,Civ.C.) 1 Lender's Name f PROPOSED MAX. OCC. Lender's Address .� � PERMIT FEE 25. 00 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, *andleb authorize representatives of this County to enter TOTAL FEE 25 ,00ea ove�iodpert r inspection purposesSEE REVERSE FOR EXPLANATORY LANGUAGE S attire of Permittee Date WORKERS'COMPENSATION DECLARATION .M444 MISC:tLLAlVtvu� Hrt'r_r�.t,►r rvry 20-0063DPW 12/90 Iy hereby affirm that i have a certificate of'consent to self -COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION irsure,or a ceahficate of Workers'Compensation Insurance, or i'tertified copy thereof (Sec 3800, Lab C) _ an Policy No. ComFOR APPLICANT TO FILL IN BUILDING /4�� r py, - - !/ p BUILDING ADDRESS �p ADDRESS• HCertified copy Is hereby furnished. 10,?3 CA's TUAbPS OF— ' LOCALITY Certified copy is filed with the county building Inspection . CITY ZIP Q� NEAREST -_•,r department 1 7EMPl� C/TT 917 CROSS ST Date Applicant SIZE OF-LOT NO OF'BLDGS NOW ON LOT DISTRICT N G UP TYPE SSED BY CONST , :" CERTIFICATE OF EXEMPTION FROM,WORKERS' - TRACT - BLOCK LOT NO. v J ` COMPENSATION INSURANCE ' MAP HIGHWAY NO ICIRCLE, STATE MAJOR SECOND LOCAL (This°section need note be'completed if the work involved, ASSESSOR MAP BOOK PAGE PARCEL U SPECIAL CONDITIONS ;by"the•permit is for'one hundred dollars ($100) or less.) OWNERTEL NO I certify that in the performance of the work for which this property 'lfh�{fUNG LL 62bs72719 permit is Issued, I shall not employ any person In any manner; so:as to'become subject'to the Workers'-Compensation Laws ADDRESS OCCUPANCY GROUP =.,Date ApplicantZIP- r n 1 Q -� CITkosC=m � /0�' NOTICE TO APPL-ICANt' If, after making this Certificate- OCCUPANT LOAD- _ .,;'6f-'Exemption;,you should become-sub,lect to' the Workers'- APPLICATION FOR " . EXIT HARDWARE '`Compensation provisions of the Labor Code,you must forthwith' comply with such provisions'or,this permit shall be deemed TRAILER USE❑° GEOLOGY INSPECTION❑, : _ No Spec Knowl 'revoked ❑ ; OCCUPANCY INSPECTION❑ Panic Devices' ❑ - ' LICENSED CONTRACTORS DECLARATION` " ,.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 �- NO OF EXITS and Professions Code,and my license is in full-force and effect- S - SPACEs G• 'REO;D PROVIDED License Number - LIc Class PAcl= ' ' Contractor -' - Date LIMITED TIME USE� _ _ - - d' -` •`rc .z - DATE r - DATE ❑ I am• exempt from the licensing ,requirements as 1 am a FROM TO licensed' architect or a -registered professional engineer INSPECTOR'S acting in my professional capacity(Section'7051,Business SIZE OF NO.OF SIG ATURE and Professions Code) EXISTING BLDG; '. G ! STORIES •-,Lic.•or Reg No' " Date PRESENT USE OF BUILDING )e �(V ST�i�ro FINAL APPROVAL'*' b �_p HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE �•;�hereby affirm that I am exempt,from the Contractor's License "L-aw. for the following reason (Section 70315, Business and �-PYofeSSlons Code): f. r NO PARKING `� a- ` -- - Ir - , SPACES PROVIDED ❑ I, as owner of the property, will do the work,and the structure Is not intended or offered for sale"(Section 7044X PROPOSED USE OF BUILDING a Business and Professions Code) 'CONSTRUCTION'LENDING AGENCY -1 hereby affirm that there Is a construction,lendmg agency for,' r` a the°-performance of the work'for which this-permit is Issued (Sec:3097, CIV C) ,r 5 PROPOSED'MAX OCC. ? Lender's Name APPLICANT(PRINT)', v. TEL NO k' ;_• i _ - , Lender's Address ADDRESS .'I certify that I'have r`ead'this application and state that the - -= above information is correct.-I agree to comply with all County PERMIT FEE ordinances and•State,laws relating to building construction,and ' e hereby authorize representatives of this County to enter`upon ISSUANCE FEE -,.the above-mentioned property for Inspection purposes TOTAL FEE - - - - X SEE REVERSE FOR EXPLANATORY LANGUAGE t SI of Permittee - Date - �< ' I ' WORKERS'COMPENSATION DECLARATION 76M"4CE 875(11-84) MISCELLANEOUS APPLICATION • ' affirm that I have a certificate of consent to self COUNTY.OF LOS ANGELES BUILDING AND SAFETY DIVISION insurere,, o or a certificate of Workers'Compensation Insurance,or �[ a certified copy thereof(Sec.3800,Lab.C) �U I Policy No. Company r FOR APPLICANT TO FILL IN .URGE lSS Certified copy is hereby furnished. g ■uanlNG s LOCALITY ,. wooNs 'a' Q {� I I Certified copy is filed with the county building inspection. LOCANEAREST department. LiT Y.: CROSS ST, Date Applicant NEAREST DISTRICT NO. GROUP TYPE PR 'CES$SO BY CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' AL ��1 �� eoNSr. COMPENSATION INSURANCE DHS CR IPTI ON LOT NO. BLOCK MAP HIGHWAY - no. (cIRcUE) STATE MAJOR SECOND LOCAL NO,OF BLDG$. (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.) USX of - 8121 Or LOT - EXISTING BLDG. L� o Q I certify that in the performance of the work for which this C permit is issued,I shall not employ any person in any manner OWNER ® C so as to become subject to the Workers' Compensation Laws. MAILi1��\ , C 3 OCCUPANCY GROUP t Date Applicant C_ NOTICE TO APPLICANT: If, after making this Certificate of CITY f �� n no� OCCUPANT LOAD ° Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- ❑ I with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION C] Panic Devices I I hereby affirm that I am licensed under provisions of Chapter SAFETY,PERMIT1:1 (Li9T ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the No. OF Exlrs Busi- ness and Professions Code,and my license is in full force and Q effect. a 0-r— 6U PARKING REO,D PROVIDED r� 9PACE8 License Number Lic. Class '` } jJ k�' �^ LIMITED TIME USE ' I Contractor Date - DATE OAT! _ FROM: TO: I am exempt from the licensing requirements as I am a i licensed architect or a registered professional engineerINSPECTOR'S SIZE OF No.of acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIE9 SIGNATURE iness and Professions Code). �. FINAL APPROVAL ' Lic.Or Reg.NO. Date PRESENT USE OP BUILDING ' I U ti «» HOME OWNER-BUILDER DECLARATION NO. ON EXISTING BUILDINGS ON LOT AND USE J I iI 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 1, as owner of the property, will do the work and the SPACES PROVIDED �% �. ,•t structure is not intended or offered for sale (Section I 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY Is IPROPOSED USE OR BUILDING I hereby affirm that there is a construction lending agency10 for the performance of the work for which this permit is a issued(Sec.3097,Civ.C.). C o , l,/ Lender's Name PROPOSED MAX. OCC. Lender's Address I PERMIT FEE CD 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 OD i upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature�f ern it e Date Yr'1' t40RkERS'COMPENSATION DECLARATION .�sMaaa' s ; er _ CE 875 (tt-aa) MISCELLANEOUS APPLICATION I hereby affirm that [ have a certificate of consent to self ,F COUNTY OF LOS ANGELES B3UILDING AND SAFETY DIVISION ✓ insure, or a certificate bf Workers'Compensation Insurance,or __ a certified copy thereof-(Sec.3800,Lab C a " u Policy No. - Company FOR;APPLICANTTO FILL•IN. BUIL°ING D ' 3 ADDRESS Certlfied,copy is hereby furnished. I BUILDING LOCALITY ADOR ESS. 0 8 ' i Certified copy is filed with the county building'rnspection g LOCALITY NEAR EST department. / p CROSS ST. _ ° -Date 'Applicant : NEAREST tl19TRICT�}NO' GROUP OI CESSED BY ` p, _ CROSS ST ` U " I. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL IC T3 I COMPENSATION INSURANCE DESCRIPTION LOT-NO BLOCK MIP NIG iwAV Nu: '• (cIRCLC) _ 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 (S100) or less.) USE of 1 - - SIZE OF COT EXISTING BLDG., -I certify that in`the performance of the work for which-his a _ permit is issued, I shall not employ any person in any manner, % OWNER so as to become subject io the Workers' Compensation Laws. OCCUPANCY GROUP -_- X yO w � T I i s - A S `-r Date applicant _ NOTICE TO APPLICANT [f,'after making ibis Certificate of, CITY �k '� NOL `IlTr - (a 2_ t I OCCUPANT LOAD. - Exemption, you should- become subject to the'Workers' APPLICATION FOR �EXIT'HARDWARE � Compensatiori'provisioits'of the Labor Code, you must forth 1' ,- - "- • ` i with comply 'wuh Sucllr provisions'or this permit shall be„ TRAILER USE -GEOLOGY INSPECTION i = NO Spec.Know[.' a deemed resoked. — - _ `- Lx s' . Panic Devices LICENSED_CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I ani licensed under provisions of Chapters SAFETY PERMIT (LIST ITEMS BELOW) � ' 9 (commencing with Section 7000) of Division 3 of the Bust- No OF Exirs - ness and Professions Code, and my license is in full force and ING REO'D �J PROVIDED - - • - SPACES effect. License Number Llc Clas's w LIMITED TIME.-USE Contractor Date' N DATE DATE _ F40M '•O I am z-,empt from -lie licensing"requirements is I am a'" INSPECTO'R'S i licensed architect or "a re^__rstered brotessional engineer ;IZE of No o� f SIGNATURE 4 Z acting 'in mN 'prot eSslonal caval,n, ISectlon /OJ I BUS- =XIS-ING 9LDG - STORIES mess and'Professions Code) , ' PRESENT USE OF 9UILDING F',1NAL APPROVAL �i -'.Fr`- v_ Lic'or Ree No. I Date _HOME OWNER,BUILDER`DECL-\R aTION, t NO OF EXISTING BUILDINGS Q,` FE «. - ,• ON LOT-AND USE l I hereby aaffiini that. i am,_e\empt'trom the Contractors I License Law for the follwwing reason tSection 70.31'5 Busi- I� ness and Piofessioris Code) No PARKING 0000-0001 11/1, SPACES PROVIDED- _ " '�,, -511699 1, as owner of the property, will do-the `i,ork ind the :( l 1 fly ��J structure is not untended or ottered tor-sale (Section t 7044.Busjness and Professions Code) ° - CON STRC%CTIOv_LENDING -\GE�1C1 PROPOSED"USE OF BUILDINGe I hereby"aum'that 'there is s construcuori lending ienev for- the°performance of the work for which this permit is issued (Sec. 309.7,Cn.C i h ` Lender's Name " r PROPOSED MAX .00C Lender's Address ( 25. 0' a PERMIT FEE' - [ certify that I have read this application and state that the : abo%e information is correct I agree to comply with all County i iSSUANCE FEE ordinances and State lairs relating to building construction, , J _ and h y�authorizentatwes of thts,County-to enter , TOTAL FEE 25.00upon n aoperty for inspection purposes ; �- SEE REVERSE FOR EXPLANATORY LANGUAGE 4 • g Si7natur ei n .n;tiee g D,ue = -