HomeMy Public PortalAbout9152 LAS TUNAS DR_Miscellaneous__ WOR•''iiRS'COMPENSATION DECLARATION 76M444
d CE 875(11-84) MISCELLANEOUS APPLICATION
I her�13y 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 fl
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING Y✓
�* ADDRESS O/`
FICertified copy is hereby furnished. PDRESSqlv= _ ( -i14 (WNC\S 17 V_ LOCALITY
ADDRESS ✓NJ lY
FICertified copy is filed with the county building inspectionOCALITY NEAREST
department. CROSS ST.
Date Applicant EAREST 019 TNO. GUP TYPE P R?,�,17 ED BY
CROSS ST. U// CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECO 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
IZE OF LOT EXISTING BLDG, d
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 V OWNER 5(,4 W ) CuN �(�1 ' y
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP;=' -
AIL Q ^� t n
A DRfi59 1.�� �I Lis 1 u1���j 10 � � '`ti.L� l?�-)�.I .,i l�}�..', I��+'�
Date ApplicantLU
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL' OCCUPANT LOAD
Tom, f,.e NO. 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.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI ❑ (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 r ,
V PARKING REQ'O PROVIDED
effect. (�
SPACES J
License Number Lic. Class 7i SJ LA 5 T4"A
■A/ LIMITED TIME USE
Contractor Date �� r _7S V DATE DATE
)p/I Oj / ���. PROM:
I am exempt from the licensing requirements as I am a `I�/I w TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- E TING BLDG. STORIES SI NATURE
iness and Professions Code).
®u Q�
FINAL APPROVAL
PRESENT USE OF BUILDING 1l.
Lic.or Reg.No. Date
AA
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE O O,O O v 8
I hereby affirm that I am exempt from the Contractor's 0 O.0—8 8
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 Z 9 5.1.7 A
structure is not intended or offered for sale (Section # 0 0 0 • 88
7044,Business and Professions Code). '0 0 0 0 0 0 • z
CONSTRUCTION LENDING AGENCY PROPoseD USE of BUILDING O O.O O'$S
I hereby affirm that there is a construction lending agency L r /( D
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.):
Lender's Name /n
PROPOSED MAX. OCC. c V r
Lender's Address J CCCCIIII
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
u the -mentio ed property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
-Z2- 4g
Ignature of krmittee Date
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. CompanyFOR APPLICANT TO FILL IN Bu 11. NG
ADDRESS
OCertified copy is hereby furnished. BuaDIss O LOCALITY G!
❑ - AD D R E'S S �, L4Tf./ �'S > '
Certified copy is filed with the county building inspection NEAREST
LOCALITY CROSS ST.
department. /
Date Applicant NEAREST - DISTRICT NO. P TYPE JPROC)ESSF -BY
CROSS ST. b o CONST',.,/,
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL QrZ
DESCRIPTION LOT NO. BLOCK mAP HICHw AY
COMPENSATION INSURANCE �Qp� STATE MAJOR.SECOND LOCAL `�
(This section' need not be completed.if the work involved NO. of SLOGS.TND• CON aTRACT NOW ON LOT _USE ZONE[=CIAL CONDITIONS -
by the permit is for one hundred dollars ($100) or'less.) USE OF
SIZE OF LOT EXISTING BLDG. L� - -
I certify that in the performance of the*work for which this �.
permit is issued, I shall not'employ.any person in•any manner•x owNER
so as to become subject to the Workers' Compensation Laws./ MAIL N ��p� �//� OCCUPANCY GROUP
ADDRESS `.� • Lft S 1 ul` As. Y � N LU
/
Date Applicant ('
p TEL. (n
NOTICE TO APPLICANT: If, after making this Certificate of � CITY F_ �� No. ,� —Z. (J 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 C3 No Spec. Knowl. ❑
deemed revoked.
OCCUPANCY INSPECTION Panic Devices El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW)
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
SPACES REq'D O PROVIDED �.
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 INSPECTOR'S'
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES - SIGNATURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL /' 1
Lic.or Reg.No. Date
HOMEOWNER-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 0 2 9, /,�+ f1
(1
�'I; as owner of the property, will-do the work and the G 7
structure is not intended or offered for sale (Section #'o a'io -.8 8
7044, Business and Professions Code). ,PROPOSED USE OF BUILDING ' 'O
® a`a o o a o sn
CONSTRUCTION LENDING AGENCY
I-hereby affirm that there Js a construction lending agency O .11;,0.'-8 1
for the performance of the,work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name .. PROPOSED MAx: OC C.
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 u orize representatives of this County to enter TOTAL FEE o0
h upon the a mentioned property for inspection purposes. SEE,REVERSE FOR EXPLANAR LY ANGUAGE
f TOC
3 S��/
Signaturetof, rmittee /Date / -
�I •
WORKERS'COMPENSATION DECLARATION CE 875(11-84) 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. BUILDING
ADDRESS 1E f LOCALITY
1
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST
DISTRICT7. TYPE 'P:JS E BY
CROSS ST �O J CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK M HIGHWAY
NO. F BLDGS.
NO. (CIRCLE) STATE MAJOR SECOND 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
- Y
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 any manner owNER of; L (f
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP
O
Date Applicant ADDRESS L~�LI
TE
NOTICE TO APPLICANT: If, after making this Certificate of CITY �' rN . D OCCUPANT LOAD D_
Exemption, you should become subject, to the Workers' APPLIC ION FDR` EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth
with comply with such provisions or this permit shall be TRAILER USE ❑ GE OGY INSPECTION ❑ No Spec. Know[.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIOr3
1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. WANE' PARKING REQ'D � PROVIDED
�• SPA CES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
I-am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STOFROM: TO:
RIES IGNATURE
inessand Professions Code). ) FINAL APPROVAL �Ifiyk,
PRESENT USE OF BUILDING
Lic.or Reg.No. Date )
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS141 91 p p�'p E
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 0-000-000 s
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
��Z . , fIL� r`~
� .
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 Od ,
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 do
fon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re of Permittee ate
WORKERS'COMPENSATION DECLARATION 76nn444
CE 875 (11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND.SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING DDRESS url LOCALITY
DCertified copy is filed'with the county building inspection LOCALITY ` NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST. 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
IZE OF LOT EXISTING BL G. d
I certify that in the performance of the work for which this
o
�f
permit is issued, I shall not employ any person any manner OWNER �/II I- t 14,4
so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP
647:5 TUN45 � O
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY �� No� ,} p OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLI ATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth
with comply with such provisions or this permit shall be TRAILER'USE ❑ GEOLOGY INSPECTION ❑ No Spec. Know[. ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
El
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING
SPACES REQ'D D PROVIDED D
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 INSPECTORS
acting in my professional capacity (Section 7051, Bus- XISTING BLDG. STORIES NATURE
iness and Professions Code).
FINAL APPROVAL
PRESENT USE OF BUILDING A�l
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS .3:31
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's :+:3
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING NO ME
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). (_E ! F(f— i i�¢1i mx
PROPOSED USE OF BUILDING, amii e•'��
CONSTRUCTION LENDING AGENCY v _ 1 i
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 6�
PERMIT FEE
I certify that I have read this application and state that the
above information is correct.I agree to comply with a County ISSUANCE FEE
ordinances and State laws relating to building con truction, O
and hereby authorize representativ o this Count to enter TOTAL FEE
upon the above ntioried pr nspection p roses.
SEE REVERSE FOR EXPLANATORY LANGUAGE rt
S nature of Permittee Date I
WOR7CERS'COMPENSATION DECLARATION
CE 875(11-84) MISCELLANEOUS APPLICATION
CE 875 r
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 'll�JIJ
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN64_ J) BUILDING
ADDRESS S�
Certified copy is hereby furnished. BUILDING ALITY
ADDRESS �I
Certified copy is filed with the county building inspection OCALITY EAREST
department. CROSS ST. ( ��
Date ApplicantREST DISTRICT GROUP TYPE / PROC ED B
CROSS ST. // CONST. /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL /U( IV/
COMPENSATION INSURANCE, DESCRIPTION LOT NO. BLOCK MAP
NO. F BLDGS. NO. J STATE MAJOR SE CON OCAL
ls�� (CIRCLE)
(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
1' V
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. \!
permit is issued, I shall not employ any person in any manner OWNER o
so as to become subject to the Workers' Compensation Laws. IL E OCCUPANCY�GROUP: jh /�� W
ADDRESS 2 47 , S �C/ O
Date Applicant ` ,
rEL.
NOTICE TO APPLICANT: If, after making this Certificate of IrOCCUPANT LOAD a-
Exemption,
NO. L 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 bea
deemed revoked. TRAILER USE ❑ GEOLOGY INSPECTION ❑ 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
effect. PARKING
SPACES REQ'D O PROVIDED D
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
0 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF FROM: TO: INSPECTOR'S
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date PRESENT 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): PARKING
0 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). —+
.POSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY0:-8 8
I hereby affirm that there is a construction lending agency ZlQu
for the performance of the work for which this permit is 0.0 0 0= 8 8
issued(Sec. 3097,Civ.Q.
Lender's Name 2 6 6 2 6 A
' PERMIT FEE PROPOSED MAX. OCC.
Lender's Address # o o • • 88
1 certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE •e,• o o • o o
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE aa0f-8 8
upo_U t e above-mentioned property for inspection purposes.
>e� SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re of Permittee(_ Date
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 APPLICANTTO FILL IN ADDRESS
DCertified copy is hereby furnished. AUOREss q D)-, LOCALITY,
Certified copy is filed with the*county building inspection NEAREST �s
department. LOCALITY -�--� CROSS ST.
Date Applicant AREST1 DISTRICT NO. GROUP TYPE PRO SSED BY
CROSS ST. ILP TLfL � CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK mAP
HIGHWAY
CIRCLE) STATE MAJOR SECOND LOCAL
( IZ
(this section need not be completed if theNO. OF SLOGS..work InVO1Ved TRACT NOW ON LOT , US'F ONE 'SPE
CIAL CONDITIONS O
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 irrany manner WNER +Z0J>0y rl� U
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
,/`�AIL CL "
ADDRESS �Llj �,�5 .rW
Date Applicant TEL N
NOTICE TO APPLICANT: If, after making this Certificate of CITY (_ NO- 2 6J 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 a NO Spec. KnOWI. El
deemed revoked. D
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic D@VIC@S
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT'n (LIST ITEMS BELOW)
vv(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 PARKING.
effect. SPACES ' REQ'D E:= PROVIDED D
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 slzE OF NO. OF INSPECTOR'S
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions,Code). ESENT USE OF BUILDING FINAL APPROVAL
Lic.or.Reg.No. Date ,�L.��
. . ,Li S�Ere-'
HOME OWNER-BUILDER DECLARATION NO.OF'EXISTINGL6UILDINGS
- 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-
NO. PARKING
-, a _
ness and Professions Code): SPACES PROVIDED �;3.0 24 A
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section # 0''0 0 0 8
7044, Business and Professions Code). Ro o'0 1 0 0 0 0OPOSED USE OF BUILDING In
z
CONSTRUCTION LENDING AGENCY O Z 2 I'—8'4
I hereby affirm that there is a construction lending agency ILI L5 6^t¢, x '
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
� p' he above-mentioned property for inspec ' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee l5ate
WORKERS'COi•IPENSAT[ON 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
Certified copy is hereby furnished. r UILDING JJ ze—
LOCALITY
ADDRESS 9/,S`z b-• (Lfy4(.'1'ly�l� ..�a '+
0 Certified copy is filed with the county building inspectionNEAREST
department. LDCALITY CROSS ST.
Date Applicant EAREST II DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
DESCRIPTION LOT NO. - BLOCK ,MwR GNwwY
COMPENSATION INSURANCE srA rE MAJOR SECOND LOCAL
NO. OF BLDGS.. ' NO. � (CIRCLE) Q.
.(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE .SPECIAL CONDITIONS O
by the permit is for one hundred dollars ($100) or,less.)- U
"� USE OF
SIZE OF LOT EXISTING BLDG. �'` cc
I certify that in.the performance of,the work for which this
permit is issued', I shall not employ any person in any manner d 16WNER
so as to become subject to the Workers' Compensation Laws. AIL T OCCUPANCY GROUP'i AMU
Lij
ADDRESS I•S`�Z G►•4 -7�� -F�,►= T. Ca s �.
-Date Applicant to
TEL' OCCUPANT LOAD Z
NOTICE TO APPLICANT: If, after making this Certificate of CITY T rvo. ; �C+^-2 �j _
Exemption, you should become subject to the Workers" AP ICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply'with such provisions or this permit shall be TRAILER USE E] - GEOLOGY INSPECTION 0 No Spec. KnOWI. ❑`
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)
-9 (commencing with Section 7000) of Division 3-of the Busi—
ness and Professions Code, and,my license is in full force and-
PARKING
6ffeCt. � SPACES REq'D O PROVIDED O
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 INSPECTOR'S
R's
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
NAT
iness and Professions Code). FINAL APPROVAL ' 7 J)
S ENT USE OF BUILDING G7,
Lic.or Reg.No. Date (J
HOME OWNER-BUILDER DECLARATION ON 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 7-03i.5, Busi-
ness and Professions Code): NO. PARKING
- - � - SPACES PROVIDED I
Q I, as owner of the property, will do the work and the
structure is .not intended or offered for sale (Section z 9 1 8.8 A-
7044, Business and Professions Code). . , `
0R,OSED USE OF BUILDIN " ` 'O O O O'8 8 '
CONSTRUCTION-LENDING AGENCY
`I hereby affirm that there is a construction lending agency o 0 o D o D o z
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). . 0 212 4 .8.4
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 Pereby authorize'representatives of this County to enter TOTAL FEE
upo the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Permittee Date
WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
"I i@reby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
1®insure, or a ceriificate of Workers'Compensation Insurance,or 'fl
a certified copy thereof(Sea•3800,Lab.C.)
Policy No: Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. UILDINGCl
ADDRESSI,r.L L � LOCALITY
. -t-. 7-ir�iNS
ElCertified copy is filed with the county building inspection NEAREST
department. - LocALITY Rip I ell y - IJ�Z�J
ceOSS
sr.
Date Applicant" AREST {n ,_ - DISTRICT NO. GR P TYPE PROC S DB.Y
CROSS ST. •YV✓4/-•�A�74� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL VV
.DESCRIPTION LOT NO. BLOCK MAP ' t HIGHWAY }
COMPENSATION INSURANCE NO. WQd (CIRCLE) STATE MAJOR SECON LOCAL - CL
OF
p TRACT - NOW ON LOT S -
(This section need not be completed if the work involved USE zorvE SPECIAL CONDITIONS O
by the permit is' for one hundred dollars ($100) or less.)
USE OF
SIZE OF LOT EXISTING BLDG. �� tr
I certify that in the performance of the'work for which this
permit is issued, I shall not employ any person in any manner NER
so as to become subject to the Workers' Compensation Laws. IL `per /I `J� _/�L /�{)� OCCUPANCY GROUP LVV;A
D SS �' L/T� L u/`��7 s, 011 ✓� CLDate - Applicant' to
n Y TEL. Z
NOTICE TO APPLICANT: If, after.making this Certificate of ITY Lf,/7� l �I / NO. f �y}'�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 orthis permit shall be TRAILER USEGEOLOGY INSPECTION -
deemed,revoked. ❑ ❑ No Spec. Knowl. ❑ .
LICENSED CONTRACTORS DECLARATION occuPwrvcr IrvsPEcrwry
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. - -
SPACES
REO'D PROVIDED
- - - - SPACLL��JJ
License Number Lic.Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: To.
I am exempt frothe licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF
13m INSPECTOR'S
acting in .my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES l 1 SI NATURE
iness and Professions.Code). P ENT USE OF BUILDING /'Y" FINAL APPROVAL
Lic.or Reg.No. DateNG
HOME OWNER-BUILDER DECLARATION ON LOTAND UNo. of Exis USE BUILDINGS r ��
I hereby affirm that, I'am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
KING
ness and Professions Code): No. Pa PRO
.. ❑ ., SPACES PROVIDED
I, 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). ((( LLL
.- P OSED USE OF BUILDING S111110(4 - 3 7&'3 A '
CONSTRUCTION LENDING AGENCY �✓
-I hereby affirm that there'is a construction lending agency #-• • • • 88
for the:performance of.the work for which this permit is
issued(Sec. 3097,Civ.C.). • •
Lender's Name PROPOSED MAX. OCC.,
Lender's Address0 1.O 8 8 6
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 mspe tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Li
Signa ure of Perm�tee �� Date
WORKERS'COMPENSATION DECLARATION
CE 8754(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 herebyfurriished. -BUILDING ) �a' c l'M LOCALITY
DADDRESS �. ias L!�'as �
Certified copy is filed with.the county building-inspection NEAREST
department. _LOCALTY 7 cRoss ST.
Date Appli.Cant 'AR EST LOM�7 "' DISTRICT NO. GR UP TYPE . PROCE ED BY "
CROSS ST. _ -� CONST. /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL - LSO I/
COMPENSATION INSURANCE
DESCRIPTION LOT NO. BLOCK MAP //�` HIGHWAY }
NO. �Jv (CIRCLE) STATE MAJOR SECOND LOCAL ,%
(This section ,need not be completed if the.work involved No. of BLDGs: 0
P 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 SIZE OF LOT EXISTING BLDG.of the work for which this Q
permit is issued, I shall not employ any person in any manner W N E R gUAl S•40 �� R
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP 7F' P�'' W
Date Applicant C--ADDREss !`j,z 4S 7-d4/4g 01;i. [L
U)
TE
NOTICE TO APPLICANT: If, after making this Certificate ofrT-r M L& NO. Z�f� — �2 7 v OCCUPANT LOAD
Exemption, you should become subject to the Workers''
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be, -TRAILER USE E] GEOLOGY INSPECTION,❑ No Spec. Knout I. ❑" '
deemed'revoked.'
LICENSED.CONTRACTORS DECLARATION OCCUPANCY INSPECTION Q Panic D@VICeS D
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT L i (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
Hess and Professions Code, and my license is in full force and
' PARKING-
- - SPACES REQ'D E:= PROVIDED
effect.
License Number Lie.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 INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
ihess and Professions Code). L' u E FINAL APPROVAL' , e
r2ESE NT USE OF.BUILDING - / / G� XIL4_�Q
Lic..or Reg.No. Date
HOME OWNER-BUILDER DECLARATION No. of EXISTING BUILDINGS
„ ON LOT AND USE ,
I hereby affirm'that, Iam exempt from the Contractor's
License Law for.the following reason (Section 7031.5, Busi- p
NO. PARKING Z 2 91&2 A
nessand'Professions'Code): - SPACES PROVIDED - -
OI, as owner of the property, will do the work.and the # s e •'s 8
structure is not intended or offered for .sale (Section _ p I
7044, Business and Professions Code). . J ))��//�� Q
ROPOSED USE,OF BUILDING L• !/r•pR S*OF� ®I'O IB;O.O'O O
CONSTRUCTION LENDING AGENCY
I'"hereby affirm that there is 'a construction lending agency � 2 � �—8 2
for the performance'of the work for which this permit is
issued(Sec..3097,Civ:C.).
Lender's Name _ PROPOSED MAX. O'CC. -
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 IssuArieE FEE
ordinances and State laws relating to building construction,
and hereby'authorize representatives of this County to enter TornL FEE
upon �ovo ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat-ure of Permi tee Date
WORKERS'COMPENSATION DECLARATION
CE875(1 1-8 1r'- ----'" M IS—C E`•�VS APPLICATION
CE 875
I hereby affirm that 1 have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or ,
a certified copy thereof(Sec. 3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FLL-CATV BUILDING`� ADDRESS
Certified copy is hereby furnished. BOILDING <�s � /� �+ LOCALITY
XX AU DRESSLf/(/ J
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. xy. �/ e__ CROSS ST.
Date _Applicant NEAREST DISTRICT NO GRQQQUP TYPE CE59E0 BY
CROSS ST. "ny //� CONST.
C'ER"III ICA"I'E OF EXEMPTION FROM WORKERS' LEGAL ,A
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.
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manneXX OWNER of buil ding o Co?d EN
so as to become subject to the Workers' Compensation Laws. IIIAIL OCCUPANCY GROUP
Date_ Applicant—, ADDRESS l�j�, S L!N` S C-
NOTICE TO APPLICANT: If, after making this Certificate of CITY rTEL.
OCCUPANT LOAD °
Exemption, you should become subject to the Workers' A PLICATION FOR EXIT HARDWARE: _
Compensation provisions of the Labor Code, you must forth ❑
with comply with such provisions or this permit shall be TRAILER USE E] 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
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 full force anix
effect. Name of business 1 u PARKING REWD
SPACES PROVIDED
License Nllmbl'r —__..__._ Lic. Class LIMITED TIME USE
Contractor__--_—__ Date DATE DATE
FROM: TO:
El I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR•
NAT
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S O E
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING irk_
Lic. or Reg. No.--------- Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS C f D 1 I
ON LOT AND USK - y
Itl-li'i
I hereby affirm that I ani exempt from the Contractor's li� r
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
El1, as owner of the property, will do the work and the SPnces 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._---_--------------- ---------
25.00
I certify that I have read this application and state that the PERMIT FEE
A, 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 above-mentioned property for inspection purposes.
XX XX SEEREVERSE FOR EXPLANATORY LANGUAGE
R`ORI:ERS' C01iPE\$..)TION DECLARATION 76M444
i aaI
ce a�� MISCELLANEOUS APPLICATION
:t
I hereby affirm that I have a certificate of consent to sett COUNTY OF LOS .-ANGELES BUILDING AND SAFETY DIVISION
insure. or a certificate of��'orkers'Compensation Insurance.or
a certified copy thereof(Sec. 3800.Lab.C.).
Polio No. _(.ompan}' FOR APPLICANT TO FILL IN B
T A
UILDING
Certified copy is hereby furnished. LD �`
REING DDRESS
LOCALITY
BAUDDISS1,95fZli2
I 1 Certified copy Is filed with the cot[nn building inspection LOCALITY NEAREST
department. Temple City CROSS ST.
Date Applicant NEAREST DISTR T N GR P TYP OCESSED BY
CROSS ST. �O/n� ��� , CONS
i CERI'll \TE OF LSENIPTION t=RO)l '.1QRI\CRS LEGAL
L1)NIPENS: rION INSLRANC! DESCRIPT;ON I LOT NO. 'BLOCK i AP HIGHW Hv
r10. (CIRCLE) STATE MAJOR SECOND LOCAL
' NO. OF BLDG$.
(This section need not be completed If the �york Involved I TRAC" NOIN ON LOT ��� USE ?ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars IS100) or less.)
� .y USE OF �
f SIC= OF Z516
OT Pf / i EXISTING BL.7G�� A�L
1 Certify that in thr nrru rmancC of :he 'aor4: 'or .vhiclt 'his V1��� CEJ �y permit is issued, I ;hall nut em loy :Inv ae-sun In an% manner ow LR
so as to become subject to the Workers' Campensation '._ott's. MAIL
J�Oa �NQ OCCUPANCY GROUP
ADDRESS !sO ._
I Date applicant
NOTICE TO APPLICANT: It. afrer makim_ ;!;is(c, ric;l[c ,I $j c1TY��,rj �� �j N°�� Z O OCCUPA.N- Lvai
Exemption. you should become ;nbieCt :o the \'Ilrkers'
Compens2tion provisions ui the Labor ode, you must forth I APDL.CATICN DF. .X17 yp,,Cyyq=.E: -
I tyith compiy %�itlt such provisions or -itis •-er:uit ,hail be I h — I I
i TR, IL=R JSE GEOLOGY :NSP=CT.!CN No Soec. 0c,.vl. L�
deemed;evoked. ��----;;
LICENSED CONTRACTORS DECL.aR.IT10`: N
OCCUPANCY INSPECTIOPanic Devices
I hereb} a firm :hat 1 am licensed under previsions of(_napter SAFETY PERMIT LIST ITEMS BELON) a
[ 9 (commencinL, with Section ;000) of Division 3 of :lie Bua- No. OF EXITS
ness and Professions Code. and m_y license is in [1[il force and
etlect, PARKING
SPG CES REO•D I PR C`J ID E7 I
License Nunibvr__ I_ic. Class
LIMITED TIME USE
N Contractor Date GATE ATE
z
ti ❑sI am exempt uom Ute I:icensing requirements as I atn a
9 } licensed architect or I resistered nmfessiona engineer SIZE of I No. of r+sPECTOR's
Z actin'_ :n my prCr',_ti:,[onal t'.;l::ii' ,.�:;iU:l I�_1 B[I\- EXISTING SLOG. N3700 R, SIGNATURE
9 iness and l'-cfessicns C:riiel.
FINAL APPROVAL
� 1
U
PRESENT 115E OF BUILDING
Lic.or Rei. Nu. __ D;uc i
HOME `J,1N1'R-Rl ILDER DECLARAFICIN NO. OF EXISTING BUILDINGS
ON LOT AND USE /✓/�/�/y, .� ..
I hereby affirm that I :tin exempt from site Contractor's ' ����1�L�-''•a••t=-- ?��•::_'f )r.
! License Law for the follotvirr, reason (Section -031.5. Busi-
ness and P-ofessionsCode): NO. PARKING p
vi
1, as owner of the proper}', will do the wSPACES PROVIDEDork and the
structure is not intended or offered for ;ale iSection
I 7044. Business and Professions Code). p
A PROPOSED USE OF BUILDING �•
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lendins x-encv S
4 for the performance of the Lvork for which this permit is
issued (Sec. 3097,Civ. C.).
Lender's Name _
PROPOSED MAX. OCC.
Lender's:address _
(
' [ certify that I have read this application and MPERMIT FEE 25.00ate 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 25.00
). upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORYLANGUAGE
I X - , �
Signature of Permittee Da(e
I RORhERS' ( O>;IPEVSAr1oN DELL:uZATlo\ 8 4
CE 1, aal MISCELLANEOUS APPLICATION
c= ay �^
I hereby atf;;m that I have a certificate of consent t0 self COUNTY OF LOS .ANGELES 1PUiLDiNG AND SAFETY DIVISION
insuie. w a certificate of Workers'Compensation Insurance.or
a certified copy thereof(Sec. 3800.Lab.C.I. — _
Policy No._— —Clmpan} FOR APPLICANT TO FILL IN Bli4LDING / �1
ADDRESS A u S
a Certified copy is hereby furnished. v BUIL Ne
i' n_ I, RESS /� S � Am LOCALITY 7r//M/'�,e
1 I Certified ropy is tiled With the county building inspection LOCALITY NEAREST GG-7, --�C
department. Temple City CROSS ST. 1,D M q
Date __Armllcant NEAREST /] DIST R T NO^ GR P TYPE Pf OCESSED BY
\ CROSS ST. /1p/VJ /�(IE' !— sS JI CONST.-- I Z 1
CERFiFiCATE 017 EXEMPTiON FROM WORKERS' LEGAL
i C(MPENSATiON !NS1.RANC!_ OESCRIPT:ON I LOT NO. 113LOCK ^o' GMW AY -STATE MAJOR SECOND LOCAL
NO. OF SLOGS. D�G �_
(This section need not be cm
ople red If the work Inv/lived I'R,i C" 'ItY ON LOT VS-- '.ONE SPECIAL CONDITIONS N
by the permit is for one hundred dollars ISllllh or less.) _
1 SIZE OF LOT���X2��n���1 USE OF
EXISTING SLOG. RtTA/L
I certify that in :he performance of -he .L.,rl: 'o- •chic:l his Flvpt--
permit is issued. I shall net employ any ne-son '.n any manner OWNER ,(j0/3 L�ft�il/
so as to become suhiect :o the L.torkers' C.):npensati(,n !.iws. OCCUPANC`.' 3ROUP —
LAIL _
1 Date-- applicant -- 3:� 'DDRESs /,SO 21 xvl}$ 7,WA) 5 417-
_
'FL / _
NOTICE TO APPLICANT: If. ai c- nakir._ :::is I: ii are v CIT 'f/ljrf/�� fL' �or6��2�--`��� ;- OCCUP4N- LOAD
Exemption. t•ou ;hould become itibiect :he Rockers 'y
t_ompensaliun ^ro isions .Lf the I_A)or .aide. you must tush- aP W dTIC:
} Lvith conlaic %%ilh .uih provisions or itis -ernit ;hail he I -aa,LER JSE lEOLJGY :NEP4 r.cN = u ,•,, i j
deemed e%,,ked.
I — N,o SL�..C. <: c i .
0CCUPANCY INSPECTION P3I1IC Cev;ceS ❑
LI( FNSED( ONTit,\CTORS
I hereby of}Irm 1;:It I am !ic:nsed unde-rroviI ions ii'Chavte, SAFETY PERMIT (LIST ITEMS SELCYN)
t 9 Icilnnlencin_ «ith Section 7000) of Division : ,,t :he Buss- - _ NO. OF EXITS
ness and P:lesions Code. mid me license is in .'t:!I fore,,.Ind
CI: PARKING
c'L;:. P4CES REO.O I RC'JIDED
License Nuniher _ ---- Lic. ('!a:,—
"o — -- LIMITED TIME USE
Contractor . -- ----..._..--- - DATE
N -.-_-_-.-_..–_'---__.--..- -
W —
l am exempt from :he :icensine -eouirenrents :11S I and .I
INS /I
m f licensed archiver: or a :esistcred arnfessinnal engineer slzE of No. C- JII
z actin'_ my C prot._• ional `.'.r•:L.;t�. ..:fl.):1 -ILr I, lilts- EXISTING G
SLO . --SICPECTOR'
N ATU
� iness::nd !'rutessil.ns C:)dcl. -- i- -- I
i-
J nR rcE VT USE OF ^cU1LOING FINAL APPRO AL
'
Lic.or Rec. Nu..._–_--_.----_--_ D;ffc r i �,
2 1
IiU`.!E ()R Nl R-BI:iLDLR DEC l_.,:t.,I IoN NO. OF EXISTING BUILDINGS O ♦ �-€ -'s=- iJ�ya
ON LOT AND USE U_1)
Ilereb_v ar,irnl that I .un exempt from the Contractor s
I License Law for the folloxvin reason (Section _11:1.-�. Busi-
ness and ProfessionsCode): NO. PARKING
❑ 1, as oL;'ner of the property. x0ll do the L )rk ,Ind the SPACES PROVIDED _—
structure is not intended or offered tnr tale (Section
1 7044- Business and Professions('ode).
�ONSiRUC ION LENDING, A(A-_N( 1 X PROPOSED USE OF BUILDING iv-r' /
I hereb} affirm that there is.a construction !ending :wencv S�R�
1 for the performance of the )rk for which this permit is
issued I Sec. 31)97,Civ.
Lender's Name--____-_-._--_.-- .-
PROPOSED MAX. OCC.
Lender's Address
1
I certify that f have read this application and state that the PERMIT FEE 25.00
above information is correct. I agree to ctlmpl� with all County ISSUANCE FEE
o'dincnces and State Ia"s relating to building construction.
and herebv authorize representatives of this County to enter TOTAL FEE 2)r X00
? upon the above-menti fid property for inspection pulp-1.I SEE REVERSE FOR EXPLANATORY LANGUAGE
— Sien ore of Permittee Wile
WORKERS' COMI' MA11UN 1Jt!ULArA11VLN 20-0063DPW12/90 IYL1✓L.GL.LHI1ir_vU6, Hrr—L.l\.Lt-1 i .1\.!,111
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING.AND SAFETY DIVISIO
a certified copy thereoN
I °*inure[or a certificateof,Wbfkers' Compensation Insurance,or
f (Sec.3800, Lab.C.)•"
Policy NO. Company FOR APPLICANT TO FILL IN BUILDING
i BUILDING ADDRESS ADDRESS
❑ Certified copy.is hereby;furnished g cI I Z E L+S 7-11VA LOCALITY
❑ Certified copy is filed with the county building inspection CITY—l '` zip
department. f�` f LC C(� o CROSS ST.
" T.
Date Applicant SIZE OF LOT NO.OF-BCDGS.NOW ON LOT - DISTRICT NO. GROUP TYPE PROCESSED BY
i CONST. d
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO. O
COMPENSATION INSURANCE MAP HIGHWAY O
NO. ICIRCI ) STATE MAJOR SECOND LOCAL..
(This section need not .be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($.100) or less.)
rt'y owner TEL NO.
I.certify that in the performance,of the work for which this
permit is issued. I shall not employ any person in any manner c C LU
I so as to become subject to the Workers' Compensation Laws. ADDRESS OCCUPANCY GROUP o
Date Applicant . CITY ZIP
NOTICE TO APPLICANT: If; after making this Certificate TIS 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 OC this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Know!. ❑
revoked.
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION El Panic Devices ❑
I hereby affirm that I am_licensed under provisions Of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW)
9(commencing with Section 7000)of Division 3 of the Business Name O LIS lIleSS NO.OF EXITS
and Professions Code,and my license is in.full force and effect.
PARKING• REWD C� PROVIDED F .
License Number Lic. Glass SPACES ��11
VR,4 AQ
IN
I Contractor Date cf ,� LIMITED TIME USE
❑ I am exempt from the licensing requirements as I am a DATE
FROM.. DATE
: TO:
licensed.architect or a registered professional engineer
acting in my professional capacity(Section 7051,Business SIZE OF OF INSPECTOR'S
and Professions Code). EXISTING BLDG. - STORIES -SIGNATURE.
PRESENT USE OF BUILDING
Date e
Lic. or Reg.No. - FINAL 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
.SPACES PROVIDED
❑ I, as owner. of the property, will do the work and the
structure is not intended or offered for sale(Section 7044„ PROPOSED USE OF BUILDING
Business and Professions Code). _
CONSTRUCTION LENDING AGENCY
j 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.).. PROPOSED MAX.OCC.
i Lender's Name APPLICANT(PRINT) TEL No. G.
Lender's Address
ADDRESS
I certify that I have read this application and state that the d K41 - "DQ — i A" (
above information is correct. I agree to comply with all County
� PERMIT FEE
ordinances and State laws relating to building.construction,and
hereby authorize representatives.of.this County to enter upon ISSUANCE FEE
the above-mentioned property for inspection purposes. .'
.: I .. ... TOTAL FEE
% SEE REVERSE.FOR EXPLANATORY LANGUAGE
Signature of Permittee Date