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HomeMy Public PortalAbout9103 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 CE 875 (2-80) MISCELLANEOUS :�' D �f3'RP.;PCATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure.or a ceA�aficate of Workers'Compensation Insurance,or . a certified copy thereof(Sec. 3800,Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING D -ADDRESS O -B� ❑ Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS X1.103 C,45TOAAS .ie— • .Certified copy is filed with the county building inspection NEAREST' department. LOCALITY CROSS ST. Date Applicant NEAREST - - DISTRICT NO. G OUP TYPENST. P O ESSED BY CROSS ST. �j�,{ _ CO CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL _ �• COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK Mqp, RIGRw Av 1' rvO. (CIRCLE) STATE MAJOR.SECOND LOCAL d NO. OF BLDGS. 0 (This section need not be completed if the work Involved TRACT NOW ON LOT USE ZONE SPECIAL L'C OND ITIO NS V by the permit is for.one hundred dollars ($100) or less.) USE.OF //'�` I SIZE OF LOT EXISTING BLDG. V 0 I certify that in the performance of the'Work for which this �' permit is issued, I shall not employ any person in any manner owrvER �1 C. so as to become subject to the Workers' Compensation Laws. I OCCUPANCY GROUP W MAIL ADDRESS Q 5 Pie— Cn Date Applicant l 'NOTICE TO APPLICANT: If, after making this Certificate of C.TY PL _ -� c -7 NOLTE% �i�l Z. OCCUPANT LOAD z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- A PLICATION FOR EXIT HARDWARE: with comply with'such provisions or this .permit Shall.be TRAILER USE O GEOLOGY INSPECTION - NO Spec. Kriowl. ❑ 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 Exrcs ry Fu:: ( g ) �_° I ness and.Professions Code, and my license is in full force and • PARKING effect. SPACES REq'D O PROVIDED License Number Lic.Class LIMITED TIME Contractor Date DATE j F,j DA=E -- - FROM: TO: I am exempt from the licensing .equirements 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 SIRE loess and Professions Code). " PRESENT USE OF BUILDING L FINPALAPPROV AL Lic,or Reg.No. Date HOME OWNER-BUILDER DECLARATION' ON LOT AND LAND NO. AUNG BUILDINGS USE / I herebyaffirm that, I am exempt from the Contractor's /v License Law for the following reason (Section 7031.5, Busi- �f NO. PARKING - ness and Professions Code): SPACES PROVIDED ❑ 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). 1` PROPOSED USE OF BUILDING IV�I CONSTRUCTION LENDING AGENCY �V 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 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 and hereby authorize representativ s of this County to enter u on the v m ntioned proper forVection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE L Itz a Signature of Permittee Date WOz7KERS'COMPENSATION DECLARATION CE 875(2-80) - MISCELLANEOUS -A P P L,'I eA T I O N I .he!eby affirm.'that I have a certificate of consent to self COUNTY OF LOS AN T BUILDING'AND SAFETY DIVISION insure;,:kf a certificate of Workers',Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No._4 Company FOR APPLICANT TO`FILL IN BUILDING ADDRESS �OV �• ��/.�+ ����- _ ❑ Certified copy is hereby furnished. uILDING• c •ATE�Apa L ADDRESS- �IO'3 'l. S'R�JIlAS D,QY y LOCALIT. ❑ Certified copy is filed.with the county building inspection NEAREST department. LOCALITY -•rGMpLE ej-ry CROSS ST. Date Applicant PttAREST /w��'��� DISTRICT NO. G p TYPE P CESSED BY CROSS ST. +kAPT /'��- /j CONST., / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �\ V COMPENSATION INSURANCE DESC F2IPr1oN LOT NO. BLOCK 9JQD MAP N(CIRCLE) STATE'MAJOR SECOND LOCAL - - NO. (CIRCLE) 0 (This section need not be completed if the work involved No. of BLDGS. p TRACT. - NOW ON'LOT USE ZONE SPECIAL CONDITIONS U by the permit is for one hundred dollars ($100) or less.) USE OF h //// / //� a—(p O SIZE OF LOT EXISTING BLDG I certify that in the performance of the work for which this v permit is issued, I shall not employ any person in any manner owNER U so as to become subject.to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP u - A ' • ADDRESS qe �oq 6-A5 U). Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of carr 1C—h� C%Zt C1 NOL U0�-71174OCCUPANT 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 deemed revoked. ❑ NO Spec. Kr10WI. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E] 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 effect. /�. Q PARKING SPACES REO'D o .PROVIDED License Number Lic.'Class 166 D� ISS 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 SIGNATURE iness and Professions Code). 1? FINAL APPROVAL USE OF BUILDING Vb DC7 Je Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION No.of EXISTING ON LOT AND USE USE BUILDINGS #; T FEE* , I hereby affirm that-I'am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- nessand Professions Code): NO. PARKINGSPACES PROVIDED _ ❑ I, as owner of the property, will do the work and the "' _" _ J. structure is not intended or offered for sale (Section 7044, Business and Professions Code). ROPOSED USE OF BUILDING - CONSTRUCTION LENDING AGENCY 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 PERMIT FEE OCA 7� I certify that I have read this application and state that the ove information is correct.-I agree to comply with all County ISSUANCE FEE or ances and State laws relating to building construction, TOTAL'FEE and- ereby a thorize representatives of this County to enter I� U he entioned erty for ins p n prposes. SEE REVERSE FOR EXPLANATORY LANGUAGE'_ tq Si ur ittee D WORKERS'COMPENSATION DECLARATION CE 875 .(11-84) M I SC E L LA NIEO U S 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.C.). . Iv Policy No. Company FOR APPLICANT TO FILL IN BUILDING �� �1 ADDRESS nz Certified copy is hereby furnished. BUILDING`S �; L ur' LocwLlrr tjC ADDRESS R ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST 67 department. CROSS ST. Date Applicant NEAREST DISTRICT NO, GROUP TYPE P ESSED BY CROSS ST. CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DEscRIPr1DN Lor NO. BLOCK MAP HIGHWAY rvo. (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 a I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. O permit is issued, I shall not employ any person in any manner OWNERIDFMAIARP so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ® a ADDRESSV- qioq TONAL ~ Date Applicant R LLIJ NOTICE TO APPLICANT: If, after making this Certificate of CIT*— C—M1E- c(T'9 No.,, g18 28�G- 7 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 PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busr NO. OF EXITS ness and Professions Code,and my license is in full force and �I effect. 1�1A� PARKING REQ�D PROVIDED E I }� SPACES J License Number Lic. Class 4LUe Dim t LF: 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 i SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING A• � � FINAL APPROVAL �f -i/"�/ Lic.or Reg.No. Date - �!�� 6 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS / /try O FEE 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 (�'� � lj!_}jl ;� 12 i/92 ness and Professions Code): NO. PARKING l o-ji El I, as owner of the property, will do the work and the SPACES PROVIDED �: I' + i' YC 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 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 of Permittee Date WORKERS',COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS A P P L I C A T I O N 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.C.). BUILDING Policy No. Company FOR APPLICANT TO FI LL IN ADDRESS Certified copy is hereby furnished. BUILDING C ADDRESS � S �u n1 A.S LOCALITY A li!'i DCertified copy is filed with the county building inspection LOCALITYlfN��� ��� NEAREST department. cRoss sr. Date Applicant NEAREST dQ C DIST NQ G� TYPE CESSED BY CROSS ST. "t AU ST. (/pI� f�/Plr C/J. CONST, CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 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 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 manner OWNER -WU Q f �-� y . so as to become subject to the Workers' Compensation Laws. LLq/pA /� 7_D R O OCCUPANCY GROUP Ce ADDRESS , LiJ CENTc Date Applicant p w NOTICE TO APPLICANT: If, after making this Certificate of c,4, &\LD w I NO. O(� � - IS OCCUPANT LOAD z 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. El 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 `�x 6� Cit`AD / S effect. sy SPACES G TIIREQ'D PROVIDED License Number Lic. Class _ g�UC D W N� (A-hILS LIMITED TIME USE Contractor Date DATE DATE FROM: TO: 1 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 SIG TURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL C � Lic.or Reg.No. Date ' NA-I 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 M LS S F—;\li tr 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 -0 PERMIT FEE - 0�/ 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 5. W upon the above-mentioned property for inspection purposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Permittee Date' WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 I hereby affirmcrt that I have certificate, consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION . insure, or a certificate of Workers' rs'Compensatiti on Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS FICertified copy is hereby furnished. BUILDING I �� AV,ADDR ES G LOCALITY ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. 'ir �� CROSS ST. Date Applicant NEAREST �. DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. �Vr L CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 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 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 manner OWNER fi ' 1T r`, =' so as to become subject to the Workers' Compensation Laws. t OCCUPANCY GROUP � MAIL (, e CJ IAD DR ES C~ Date Applicant nn ,,, NOTICE TO APPLICANT: If, after making this Certificate of clr C{ no �,� �%7 OCCUPANT LOAD z Exemption, you should become subject to the Workers' APPLICATION F R 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. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 1` effect. 1' PARKING SPACES REQ•O I I PROVIDED License Number Lie. Class L ���✓ fR • LIMITED TIME USE Contractor Date rOv a �` DATE DATE 0 I am exempt from the FROM: TO:licensing requirements as I am a CSV 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 O © I PRESENT USE OF BUILDINGJJ1� I V Lie.or Reg.No. Date � -+�— C GC 1._. HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGSON LOT LOT AND USE - - I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- [11C. ness and Professions Code): NO. PARKING ti_3i„f�i( 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.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE 79 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 a o e-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Perkiittee Da e WORKERS'COMPENSATION DECLARATION 76M444 CE 875 (2-80) MISCELLANEOUS APPLICATION 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.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished. BUI a ss LOCALITY �. ❑ Certified copy is filed with the county building inspectio NEAREST department. LOCALITY cROSS`ST. Date - Applicant NEAREST DISTRICT JIB- GROUP TYPE JPROC7E: SED B CROSS ST.,. '' Q� CONST.. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �J COMPENSATION INSURANCE ' DEsc RIPTION LOT NO. BLOCK MAP HIGHWAY - - No. QZD6 (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 0 by the``permit is for one hundred dollars ($100) or less.) U USE ' SIZE OF.LOT _ EXISTING BLDG. - - I certify that in the performance of the work for which this X. J� permit is issued, I shall not'employ any person in any manner OW so as to become subject to the Workers' Compensation Laws. MOCCUPANCY GROUP U AD DRE L� �� tL- Date Applicant �" t� NOTICE TO APPLICANT: If, after.making this Certificate of CITY !E 1 NO. OCCUPANT LOAD Z Exemption, -you should become subject to the Workers' APPLIC TION 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 , deemed revoked. ❑ No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ Thereby affirm that.1 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 Applicant's 'Nagle" effect. r KING REO'D PROVIDED License Number Lie.Clas Romia Address — L' {� �( f�� LIMITED TIME USE Contractor Date- GS 1 iN / / DATE DATE ❑ I am exempt from the licensing requirements as I am a Phone — r FROM.: TO: 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 mess and.Professions Code). ESENT USE OF BUILDING ��� FINAL APPROVAL 0 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 SPACES PROVIDED _ ❑ 1,, as owner of the property, will do the.work and the is not intended or offered for sale (Section ;R 2 5 �,.b•A structure 7044, Business and Professions Code o a n ® (�Q OPOSED USE OF BUILDING CONSTRUCTION LENDING.AGENCY i!'•� © o o"o o • o I hereby affirm that there is a construction lending agency for the performance of the work for vdhich this permit is issued(Sec. 3097,Civ.C.). Lender's Name _ PROPOS'ED•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 NJ and hereby authorize representatives of this County to enter mon the e-mentioned property for inspect' I purEn' poses. SEE REVERSE FO XPLANATORY LANGUAGE Signature of Permittee A Date 3^'(j` WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION 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.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING // ADDRESS VIo•' ❑ Certified copy is hereby furnished. Lo15UILDING LOCALITY ADDRESS 910a • �(� ❑ Certified copy is filed with the county building inspection N NEAREST department. LOCALITY %e ei!b Olet CROSS ST.'" -Date Applicant EAREST ( DISTRICT NO.1 NO. ' G OUP TYPE PROC ED BY CROSS ST. Qjr CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL BLDGS DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. COMPENSATION INSURANCE S. No. �� (CIRCLE) STATE MAJOR SECOND LOCAL d ' OF. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESP CIAL CONDITIONS UO ' 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 0 permit is issued, I shall not employ any person in any manner wrleR• U so as to become subject to the Workers' Compensation'Laws. Q OCCUPANCY GROUP .. AD DRESS LI03 Date Applicant NOTICE TO APPLICANT: If; after.making this Certificate of Iry NO / �7d'd' OCCUPANT LOAD z Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- -with orth-•with comply with such provisions-or this permit shall be TRAILER USE GEOLOGY INSPECTIONNO Spec. Knowl. ❑ - deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY,INSPECTION Panic Devices ❑ 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 .effect. PARKING REWD E=. PROVIDED .. .. SPACES License Number Lic.Class 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 IN SIGNATGNATSPERUREE acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES . 3-ejpfd i, iness and Professions Code). eSENr USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date T?�� ' C lb NG HOME OWNER-BUILDER DECLARATION ON LOT AND SE No. OF ExIs UUSE BUILDINGS ' I hereby affirm that- L am exempt from the Contractor's License Law for the following reason'(Section 7031.5, Busi- ness PARKING - c 3'6 1.9 A ness and Professions Code): SPACES PROVIDED ❑ I, as owner of the property, will do the work and.the # D o 0 0 88 structure is not intended or offered for sale (Section,. ' 7044, Business and Professions Code). OPOSED USE OF'BUILDING O+O i O'OI O,j O'O'er CONSTRUCTION LENDING AGENCY 08.20-84 I hereby affirm'that, there is a construction lending agency 1 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 and hereby authorize representatives of this County to enter ' upon the above -menti a roperty for,inspe1I pyyrposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Y d � Signature of 9-rrKittee I 'Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION I hereby affirm that ► 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. CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILS DIESNG IDy ,45 TU LOCwurr , DR XX AD Certified copy is filed with the county building inspection `OCALITY NEAREST department. XY.�' e 1 G t �/ 1 7 D CROSS ST. Date Applicant NEAREST DISTRICT NO. GJ�f�UP TYPE � CESSED BY CROSS ST. ��� G /�S CONST/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a rG7� 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 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 `-D so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o DRESS a:::] U Date Applicant AD41 NOTICE TO APPLICANT: If, after making this Certificate of CITY No. _ OCCUPANT LOADgjgM Exemption, you should become subject to the Workers' APP ICATIONFOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- ❑ with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 0 I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 Of the Busi- SAFETY PERMIT ❑ (LIST ITEMS BELOW NO. OF EXITS ness and Professions Code, and my license is in fullforce anix effect. Name of business PARKING SPACREO'D � LL PROVIDED 1 I ES __JJ License Number Lic. Class 6 1 NSD 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 INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG TORE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING -7U Lic.or Reg.No. Date / HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS G1 ''`-'` (� 'i•)'= ='' i'-" ON LOT AND USE I I hereby affirm that I am exempt from the Contractors 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 srwcEs 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 MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE 25 - 00 above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and tate laws relating-to building construction, an'd Hereby rite representatives of this Count to enter TOTAL FEE 25 ,oQ upon thea ve ses. e timied property for inspection rpo If�_ EE REVERSE FOR EXPLANATORY LANGUAGE XX XX Si :tire of Permittee Date WORKERS'COMPENSATION DECLARATION' �E 845411-841 MISCELLANEOUS APPLICATION- , I hereby affirm that 1 have a certificate of consent self 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 APPLICANT TO FILL IN BUILDING C/J ADDRESS F1 Certified copy is hereby furnished,. BUILDING i".. XX ADDRESSqjo A4& a LOCALITY Certified copy is filed with the county building inspection . LOCALITY 'j' / ' /� /� �1 (� T. NEAREST department. XY. [� Q t�'i' l�'r ! //) (J C�IOSSST. Date —Applicant - _ NEAREST, �/— O,ISTRICT NO. .I GROUP ITYPE P ESSED BY CROSS ST. / 6-�[. j CONST CERTIFICATE.OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP RIG-1 No: (CIRCLE) STATE MAJOR SECOND LOCAL NO.OF SLOGS. - (This section need not be completed if the Work involved TRACT NOW ON LOT USE ZONE SPECIALCONDITIONS by the permit is for one hundred dollars ($100) or,less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this c°3 permit is issued, 1 shall not employ any person in any-manne3CX OWNER of buildin so as to become .subject to the Workers' Compensation I:aws. MAIL OCCUPANCY GROUP /if- c*-. Date -- Applicant - LL NOTICE TO APPLICANT: If, after making this Certificate of C Y NO. OCCUPANT LOAD v Exemption, you should become: subject to the Workers' SiAA_ gppLl TION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- _ .... with comply with such provisions or this permit sliall'be TRAILER USE E] GEOLOGY INSPECTION ❑ NO Spec. KnOwl. �. deemed revoked. _ OCCUPANCY INSPECTION ❑ _ Panic Devices LICENSED CONTRACTORS DECLARATION 1 hereby of flilll'that l Gill licensed under provisions of Chapter - SAFETY PERMIT.❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code, and my license is in full force aniX effect. Name of business PARKING SPACES REQ'D PROVIDED License Number_ Lic. Class A LIMITED TIME USE Contractor___ -__- Date DATE DATE FROM: O' .,.. I ani exempt from the licensing requirements as I am a �:u.�x �._ .= licensed architect or a registered professional engineer SIZE OF NO.OF i '-1_ft�#,� f IN$'PEIn g g / acting in SIGNATURE my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES � t inessandProfessions Code). FINAL APPROVAL PRESENT USE OF BUILDING Fl NAL or Reg. No.— _ Date — ITOMI. OWNLR-I;UIE.DE'•R DECLARATION NO. OF EXISTING BUILDINGS lbulQ 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 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 B41LDING herebv affirm that there is a construction lending agency for the performance of the work-for which this permit is issued(See..3097.Civ.C.). Lender's Naine - — — _ PROPOSED MAX.*OCC. Lender's Address—.---------- PERMIT FEE25 -00 - certil-v- that"I have read this application and state that the above information is correct. I agree to comply with 811 COUIrIV ISSUANCE FEE ordinances and. State laws relating to building construction, . - and hereby authorize representatives of this County to enter TOTAL. FEE 25 .00 upon the ab e-n ntione erty for inspection puiposes. SEE REVERSE FOR EXPLANATORY LANGUAGE XX _ XX 93�� 17w111e ot_Permittee Date a W0Kht.KJ"l,UD71'1:,`JA11V1V LLI.Lii1C•y11V:V ;blV1444 � ISCELLAIVEUU� Af�('LIC:A I IUIV I hereby affirm that I have a certificate of consent to self CE 875 (11-84)COUNTY- OF LOS ANGELES BUILDING AND SAFETY DIVISION • insure, or a certificate of Workers'Compensation Insurance,or I ' �I a.certifi8d copy thereof(Sec. 3800,Lab.C.). '-� P'-1L_2JJ Policy No. Company FOR APPLICANT TO FILL IN ADDRESS /G Certified copy is hereby furnished. X BUILDING O LAS TAADS Pr ADDRESS LOCALITY t i Certified copy is filed with the county building inspection LOCALITY Temple City cRssrepamen . os . Date Applicant NEAREST DISTRICT NO. I GrP JTYPE � CESSED BY CROSS ST. �j CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a I COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAv HIGHWAY IV D. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This Section need not be completed if the work involved TRACT NOW ON LOT U3E ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) uSE OF I 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 OWNER L so as to become subject to the [Yorkers' Compensation Laws. MAIL r OCCUPANC ROUP o ADDRESS I Date Applicant NOTICE TO APPLICANT: If; after making this Certificate of cITY NO` _ -a OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLI ' IL ION FOR EXIT HARDWARE: — 1 with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPEC71ON:1;X Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) i;z I 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.' SPACES REO.O PROVIDED N C License Number Lie. Class ZC� LIMITED TIME USE Contractor Date DATE DATE w Z I FPOM: TO: i am exempt from the licensing requirements as am a 1 licensed architect or a registered professional en;ineerI_E .OF NO, OF NSPECTO R'S acting in :nv professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code) o PR FINAL APPROVAL SSE*1T USE OF BUILDING L; Lie.or ReL-. No. Date HO:\lE OWNIER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS _ - ON LOT AND USE �`� [ hereby affirm that I am examnt from the Contras--tot`s i License Law for the following reason (.Section X03)5, Busi- ness and Professions Code): NO. PARKING ' SPACES PROVIDED I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section. y 7044.Business and Professions Code). CONSTRUCTION LENDIPROPOSED USE OF BUILDING NG.AGENCY" — ttt I hereby affirm LhMt there is a construction lending asenev i for the performance of the work for which this permit is issued k,Sec. 3097,Civ. C.). Lender's Name PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the ' PERMIT FEE 25.00 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 25.00 !. upon the abs mention property for inspection purposes. I ��Q�� SEE REVERSE FOR EXPLANATORY'LANGUAGE j v Signature of Permittee Date I ' {: I WOKKI:KJ' I.UMYh1VJAl1ULV LCtJL,H1CH11lJ1V 20-0063DPW12/90 IVIi�l.t.LLHN1= VU., Ht''Y'LIt IVIV L hereby affirm that I have.a.certificate of consent to self COUNTY OF LOQ ANGELES BUILDING.:AND SAFETY DIVISION rinsure;'or a certificate of Wbikers' Compensation Insurance, or - i a certified copy thereof (Se'c:3800;-Lab-C.), ,: I • t Policy`No. Company FOR APPLICANT TO FILL IN BUILDING UILDING ADDRESr % ADDRESS ❑ Certified copy,is.hereby;furnished. g 103 Z; J Tti OSPAML I LOCALITY ❑ Certified copy is filed with the county building inspection CITY ZIP - t department. IF—PI PLO 9 11750 NEAREST CROSS ST. .. Data � Applicant SIZE OF LOT NO:OF BLDGS,NOW ON LOT DISTRICT NO. I GROUP TYPE PROCESSED BY r t r CONST. G CERTIFICATE OF EXEMPTION FROM WORKERS,' TRACT BLOCK LOT NO. C i.. I COMPENSATION INSURANCE ': MAP HIGHWAY (, NO. (CIRCLE) STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL by the permit is for one hundred dollars ($100) or(less.) USE ZONE SPECIAL CONDITIONS Taper-t: eX TEL NO. Z iZ i I.certify that in the performance.of the work for which th ICK CyLU D 11 permit is issued:h shall not employ any person in any manne so as to become subject to the Workers' Compensation ADDRESS Laws. ^ OCCUPANCY GROUP Z 1 J rvC. �J ( Date Applicant CITY }} ZIP NOTICE TO APPLICANT: If;.after making this Certificate ��l P� IOU OCCUPANT LOAD � of Exemption, you should become subject to the Workers' APPLICATION FOR Compensation provisions of the Labor Code.you must forthwith 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 Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) { I 9(commencing with Section 7000)of Division 3 of the Busines Tame o Business NO.OF EXITS and Professions Code,and my license is in full force and effec • PARKING• REQ PROVIDED License Number Lic. Class .S }Q NO� cook M SPACES ( i I Contractor Dater ����-�-� LIMITED TIME USE .. -i ❑ 1 am exempt from the licensing requirements as I am a DATE DATE � FROM: TO: licensed architect or a registered professional engineer - r acting in my professional capacity(Section 7051,BllS1nCSS EXISTING BLDG. � ��i�C �SIZE OF NO.OF INSPECTOR'S STORIES SIGNATURE. and Professions Code). Lic. or Reg.No. - Date i PRESENT USE OF BUILDING �hFINAL APPROVAL 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 SPAC ES,PROVIDED ❑ I, f�as owner of the property, will do the work and th structure is not intended or offered for sale(Section 704 ROPOSED USE OF BUILDING QZj� Business and Professions Code). CONSTRUCTION LENDING AGENCY . �2 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued i I (Sec. 3097, Civ.C.). - PROPOSED MAX.OCC. ./J Lender's Name A PLICANT(PRINT) TEL NO. Lender's Address OADDRESS 0-3 L45 TVAJA, D r� { iI certify that I have read this application and state that the above information is correct. I agree to comply with all County PERMIT FEE I CA C? rID ordinances and State laws relating to building construction,and I hereby authorize representatives.of this County to enter upon ISSUANCE FEE S : the above-menti ned•-propert for inspection purposes. TOTAL FEE ... -SEE REVERSE FOR EXPLANATORY LANGUAGE Sign%tvr�Lrnrttee Date I WORKERS' COMVLNSALION DECLARATION z0-outs:;DPW 1 ,,u MISCELLANEOUS APPLICATION ,I hereby affirin that I have it certificate of consent W 1eh COUNTY OF LOS ANGEL.ES BUILDING AND SAFETY DIVISION insure,or a certificate of Workers' Compensation Insu micc,.of a certified copy thereof (Sec. 3800, Lab. C.) " Policy No. _ Company FOR APPLICANT TO FILL IN BUILDING ' I _.. .. _ ADDRESS - _ BUILDING DDRESS ❑ Certified copy is hereby furnished. LOCALITY _ ❑ Certified copy is filed with the county building inspection clry ( ZIP NEAREST r/(/ department. 7.- CROSS ST. Date Applicant SIZE F LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY Date----- -_ _ . . - - CONST. 11 .. CERTIFICATE OF EXEMPIION FROM WORKER`' C. TRACT BLOCK LOT NO. t I-) COMPENSATION INSURANCE _ NOP HIGHWAY Rc EI STATE MAJOR SECOND LOCAL ` IThis section need mi be.COnlple(ed if the 1\'Ork in%lol%ed ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS f. by the pennil is f r �;nc hundred dollars (�10111 or less.) f ;.. .21 I 1 certifythat in the performance of the work fol which IhiS OWNER/ _� J ; T L o. permit is Issued, I shall not employ any person in m ,Iny ,umei t so as to become subject to the Workers' Compcn,ation Laws. ADDPt,. I. l(Vt� OCCUPANCY GROUP Date —_-- Applicant C11- t ZIP — _ NOTICE TO APPLICANT. If. after making this Certificate Aa�` aJ � OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATI N FOR EXIT HARDWARE: Compensation provisions of the Labor Code.YOU must forthwith comply with such provisions or this permit ,hall be dvellled TRAILER USE GEOLOGY INSPECTION❑ NO Spec.Knowl. ❑ t revoked. - OCCUPANCY INSPECTION'K Panic Devices ❑ LICENSED CONTRACTORS DEC LARAF10N I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT O (LIST ITEMS BELOW I El 1 14 9(commencing with Section 70.00)of Division 3 of the Business NO.OF EXITS and Professions Code,and my license is in full force and.'ffect. PARKING• REQ'DPROVIDED r I License Number L.ic. Class X 't� SPACES JJ 1 I contractor Date LIMITED TIME USE j I �� DATE DATE ❑ I am exempt from the licensing requirements as I and a FROM: TO:. licensed architect or a registered professional cn;ineer L actin In Ill' roicssional capacity (Seelillil 7051. Business SIZE OF NO.OF INSPECTOR'S g } p SIGNATURE and Prulcssions ('ode). EXIS rING ULI1C;. Srl1RIF.5 _ _ LIC. Or Reg. No.. Date PRESENT USE OF BUILDING // ,� FINAL.APPROVAL .-- ' 1 I HOME OWNER-BUILDER DI.(1AR.AIION NO.or l-%ISIING BUILDINGS _ ---- - I I I ON LOT AND USE - - hereby affirm that I am exempt from the Contractor's License -- ' Law for the following reason (Section 7031.5, Business and r I Professions Code): NO.PARKING I (%A SPACES PROVIDED LDS L as owner of the property. wili Flu the cork and IIIc I, structure i1 not intended lir llil el ell TUI sale(Sl'clion 704PROPOSED USE OF BUILDING - i I Business and Professions Code). _ CONSTRUCTION LENDING AGENCY / 1 hereby affirm that there is a construction lending :igen::} Ior -r—C, (7, Ces-tNA r/a—L,f- the performance of the work for which this perini is ;slued64 PROPOSED MAX.OCC. (Sec. 3097,Civ. C'.). `�- Lender's Name _____. T-._—___ ._-_-_ -_ _ _:_...- APPLICANT(PRINT T /� TEL NO. Lender's Address ADDRESS 1 certify that I have read this application and state that the 0Lu C above information is correct. I agree to comply with all County PERMITFEE / I ordinances and State laws relating to building construction.and hereby authorize epresentatives of this County' to enter upon ISSUANCE FEE Il the abov bn d property for inspection purposes. TOTAL FEE If o X �C 0 i �� SEE REVERSE FOR EXPLANATORY LANGUAGE v Signature ermittee Date I. a 1 - WORKERS' COMPENSAIION DECLARATION MISCELLANEOUS APPLICATION n-nus ohw l a�s,o r' " I hereby affirm that I have a certificate of cunseat to sen COON-{'Y 01' LOS ANGEL.[:S BUILDING AND SAFETY DIVISION insure,or a certificate of Workers'Cumpensmiun Insmance, ur a certified copy thereof (Sec. 3800. Lab. C.) Policy No. . _ Company FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRES ADDRESS ElCertified copy is hereby furnished. >'. 9 ( Q 3 S Li d _ LOCALITY ❑ Certified copy is filed with the county building hl,pectiun CIT I �-y q department. Q}M ZIP NEAREST/ 0 CROSS ST. Date „_- A f;pl!Cant SIZE OF LOT V NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CONST. I' CERTIFIC'AII: OF EXEMPTION FROM WORKL.R`' TRACT BLOCK LOT NO. ` COMPENSATION INSURANCE MAP HIGHWAY l: NO. ICIRCLEI STATE MAJOR SECOND LOCAL (This section need n01 be hundred If rIhc• N'Ufk IIIPOI%s.) ASSESSOR MAP BOOK PAGE PARCEL .USE ZONE SPECIAL CONDITIONS r� I by the permit is for one hundred dollars la 1001 or less.) 1. certify that in the performance of the work flit which this OW NE ) TEL No. C j • permit is issued, I shall not em to In person Irl an manner — tA' S1 � (02 2d�0 --�- „! p' p ' ` y l y ADD ss so as to become subject to the Workers' C'ompen,ation Laws. 1 09 L0.5 �a D, OCCUPANCY GROUP tr' +v �., i Date------ Applicant -- Clr I ZIP NOTICE TO APPLICANT: If, alter making this Certificate �� OCCUPANT LOAD of Exemption, you should become subject to the Workers" AP LIGATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code.you must forthwith t Comply with Such provisions or this permit shall bC kiCemed TRAILER USE❑ GEOLOGY INSPECTION❑ revoked. No Spec.Know(. ❑ _ I �'I OCCUPANCY INSPECTIONN Panic Devices ❑ LICENSED CONTRACTORS I)[(TARAIION . I hereby affirm that I aim licensed Under provisions of (hapter SAFETY PERMIT❑ )LIST ITEMS BELOW I 9(commencing with Section 7000)of Division 3 of the Business No.of Exlrs and Professions Code,and my license is In full three and effect. - /\ t G'i�" a-�a.t t-lsf� PARKING• REQ'D I I PROVIDED License Number Lic. (lass115 • - SPACES I Contractor Date — — LIMITED TIME USE DATE DATE ❑ 1 am exempt from the licensing requirements asI and a FROM: TO: licensed architect or a registered professional engineer acting in f I -my professional capacity (Srrfiun 7f1;L, liusntrss SIZE OF NO.OF INSPECTOR'S I EXISTING BLDG. � STORIES - SIGNATURE '— and Professions Cudc). ---- ! - LIC. or Reg. No. _ _ Da PRESENT USE OF BUILDING S �(f fA yt--f FINAL-APPROVAL t I IIONIE OWNER-BLIILDLIt DI'.( I.ARA'IION NO.OF ilXlslINGBUILDINGS I12N LOT AND USE hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business _ I Professions Code): NO,PARKING I ❑ Las uronci of tile property. l\' ill dl� Thr �c,ltk :nut (hr SPACES PROVIDED — -- --- ----� Structure Is not intended ill' UIfCICLI TUI SaIC(SCC110ll /t1-14,$ PROPOSED USE OF BUILDING cook I ') Business and Professions Code). 5 C�b� CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency fot . the performance of the work for Mlich this pcYmii is.lssued (Sec. 3097, CIV.C.). PROPOSED MAX.OCC. Lenders Name _ _-_._.____-__-. _ -. _ APPLICANT(PRINT) TpLq 7ROLIAL- l(J^�`/F Lender's Address . ..._- .. J 1 certify that I have read this application and state that the ADDt-� �� ��� e yy� 1e C) above information is ccarect. I agree to coniply with allCounty I PERMIT FEE I ordinances and State I„vs relating to building construction,and I hereby authorize representatives of this County tU enter Upon' `ISSUANCE FEE thee above-m-eDntioneu pr, perty for inspection perp Ise12— s m UI I i/" /hn"I l!/� � /� � �f TOTAL FEE a /� 1 l SEE REVERSE FOR EXPLANATORY LANGUAGE J Signature of Permittee Date a I