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Home My Public Portal About9160 LAS TUNAS DR_Miscellaneous__ \YORKERS'CO`IPE\SATIONDECL.aR.;TI:�`J 73INCEE USLLANOUS APPLICATION r= s75 (i,-aa) .. Lus CE herebv affirm that 1 have a certificate of concent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure. or a certificate of Workers'Compensation Insurance,or �_ 1 'I a certified copy thereof(Sec. 3800, Lab.C.). Policy No. CompanyR8UILDING /�� FOR APPLICANT TO FILL IN 9i� O AG ADDESS Certified cony is herebv furnished. p Bu1LDING A AD OR ESS I(Lo ( ,>,p ��L/J� LOCA LIT Certified copy is tiled with the county building inspection X LOCALITY NEAREST department. CROSS.ST. Date Applicant NEAREST 01 TRI NP G UP TYP OC ESSED 9Y CROSS ST. `//Y CO 5- I CERTIFICATE OF EXEMPTION FROM WOR.,=S' LEGAL C / ✓ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK AAP HIGHWAY NO. OF BLDGS. No. (CIRCLE) STATE MAJOR SECOND LOCAL (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 ;collars (5100) or less.) USE DF SIZE OF LOT EXISTING BLOC. I certify that in the oerformancc of :he work for which :his permit is issued. I :hail not employ any person in my manner X OWNER (� CIL, I « J so as to become subiect to the Workers' Coroners rion Laws. OCCUPANCY GROUP X w ADDREss Date Aonlicant 6c yt 2 TEL. NOTICE TO APPLICANT: If, after makins -,his C.=Iicate of CITY �-E No. OCCUPANT LOAD - Exemption, you should become subiect ':o :he k\orkers' Como_ensation provisions of the Labor Code. you must -'or-h- APPLICAT ON FOR _X IT HARDWARE: with comply ''w'itli >u':a provisions or :his shall I;e — — { - TRAILcR 'JSE I GEOLOGY INSP_CT:ON I_ i Spec. Knowl. _ deemed reiroked. — L� I LICENSEDC:O�TRACTORS DECLAR.yTO` occ'JpANcr INSPECTION B Panic Devices 1_! I herebv affirm that I ani Licensed under provision,of C..laprer SAFETY PERMIT i7 I ,t (LIST ITEMS BELOW) - 9 icommencing with section 7000) of Division J •)i fife Busi- No. OF EXITS ness and Professions Code. and my license is infull .orce and effect. PARKING SPACES REO.O ' ' pROVID ED I ' ) License Number Lic. clan LIMITED TIME USE Contractor Date ..TE A TE I [ am exempt item 'he iirensing :equire:ner;•s s l 'an: a J licensed architect or a re__isiered -±r0iessioa;ii e±neer ;IZE of NO, O INSPECTORS actin'_' in :n%' )tot essio'nal '.:tip;Il;:i: :Section ,�•1. 5us- .XIS':NG 3LO i:. STOR!EJ I SIGNATURE mess and P-oteSsions Code I. PRESENT USE OF 3UILOING FINAL APPROVAL 12-1/- Lic.or Res. No. Dare_. - UI HOME OWNFR-BUILDER DECLARATION NO. OF EXISTING BUILDINGS D 'A ON LOT AND USE i) i1J I herebv affirm that i am exempt from ;fie ontrector s V 6 License Law for the .'cLto%%mL reason (Se;:,iun ')_I.:. Busi- tic ss and Professions Code): NO. PARKING ❑ SPACES -ROVIDED I, us owner at ;he ;J.Toperty, will do ttir •or}: Ind he structure is not intended or offered for ':aie SeLtion Business and Professions Code). _ CONSTRICTION LENDING AGENC 1 X PROPOSED 'JSE OF BUILDING I hereby affirm that there is a construction lenLiin2 ;,agency ' " „�-� I for the performance of the work for which this permit is o issued(Sec. 3097.Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender',Address J - PERMIT FEE25.00. 1 certify that t have read this application and ;tate that the above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to buildins construction. and herebv authorize representatives of this County to enter I TOTAL FEE 25.00 upon the above-mentioned property for inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE :VORKERS' CONIPENSAI-ION DECLARA im; %o-oua:,nPVd i , ,,u MISCELLANEOUS APPLICATION � `i hereby affirm that I have a certificate of concol to sellCOUNTY OF I..OS ANGELES BUILDING AND SAFETY DIVISION Ij insure,or a certificatr`,I' Workers' Compensation Insurance. or a certified cojy thereof (Sec. 3800. Lah. C.) j Policy No. _„ _ Company FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRESS ) ADDRESS El Certified copy is hereby furnished. 1 +6O LA4J`t/�C __ LOCALITY ❑ Certified copy is Filed with the county building inspection CIT ¢�-r-�- ZIP NEAREST department. VAQ If\ _ CROSS ST. Date-_-_____ Applicant SIZE OF L T NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CERTIFICAH: OF EXEMPTION FROM WORKI.RS Wrj coNsr. 1• TRACT ��\) LOCK LOT NO. L t C. COM PENSAITON INSURANCE V MAP HIGHWAY I ,.,. VV� 6 I NO. iCIR CLEI STATE MAJOR SECOND LOCAL (This section heed not he completed.If the Norte imol%cd ASSESSOR MAP BOOK PAGE PApCE r" _ ZONE SPECIAL CONDITIONS by the nermil is for one hundred Liuliarti Iti 10111 or less.) S rel '- I certil'y that ill illc performance of file P1ork for which this OWNER s TEL NO. Q'�,� 1 t pernit is issued. I shall not employ an)' person in mw manner — 1 t� 1IL- ---- -- t so as to beconle subject to the Workers' Compen,alinr; Laws. ADDRESSOCCUPANCY GROUP t" Applicant _ -_. - _ CITY ZIP NOTICE TO APPLICANT: II, after making this ( ertilic:ue t OCCUPANT LOAD of Exemption. you should become subject to the Woikcis' APPLICATI N FOR -- Compensation provisions of the Labor Code.you must 1„rlhwith —1 EXIT HARDWARE: comply with such provisions or this permit shall be deenled TRAILER USE LJ GEOLOGY INSPECTION�_� No Spec.Knowl. ❑ i revoked. . — 1� OCCUPANCY INSPECTIONN Panic Devices ❑ LICENSED CONTRACTORS 1)EC 1./%RAION hereby affirm that I aln licei;sed WIL{L'I' IY,(11 iSi0oh UI (I1:111ter SAFETY PERMIT O (LIST ITEMS BELOW I a i 9(commencing with Section 7000)of Division 3 of the Business N NO.OF EXITS and Professions Code,and my license is in full lorce and elTect. --- - PARKING• REQ'D D PROVIDED D i License Number I_ic. (lass SPACES Contractor Date ZT LIMITED TIME USE DATE DATE ❑ I aril exempt from the licensing rcquirements as I alit a FROM: TO: licensed architect or a registered professional engineer - ' acting in Illy professional capaclt) ((Section 7051. Business SIZE OF NO.OF- INSPECTOR'S Exis rING BLDG. 1ORIL S SIGNATURE � '•-' ' and Professions COLIC). — ---- PRESENT USE OF BUILDING FINAL APPROVAL Lic. or Reg. No. Date t .. _._mac- HOME OWNER-BIIIL.DLR DIA LARAIIUN NO.Of EXIS1INGBUILDINGS ON LOT AND USE 1 hereby affirm that I am ezcnlpt from the Cont'aclor's License l9, Law for the following reason (Section 7031.5. Business and Professions Code): NO.PARKING �� SPACES PROVIDED ❑ L as owner of tilt' property, will do the „ork and Iter structure is not intended lir Lllleied I0i sale (Scciion 1044. PROPOSE D USE OF BUILDING Business and Professions Code). CONSTRUCTION LENDING AGENCI" ) ~ VIii�V1G1 hereby affirm that there is a construction lending ager::\ for fire perf'ornance of the work lilr which this pernlit is issued - --- • i (Sec. 3097,.Civ. C.). PROPOSED MAX.OCC. Lender's Name JA ICA NT(PHL'JT) TEL N Lender's Address - ..__.._ _s I certify that I have read this application and state thatfheW 0 ^ �� ✓e ` ✓[ctAGry above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building constrtictiou,and hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inpection purposes. I I I OTAL FEE ;3 X ( � SEE REVERSE FOR EXPLANATORY LANGUAGE Signa t re of mit ee Date WORKERS'COMPENSATION DECLARATION 76M444 CE 875(11-84) MISCELLANEOUS APPLICATION J� I'`tby-affirm that i have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION h'ILJI'I insure,'or a certificate of Workers'Compensation Insurance,or a cegified copy thereof(Sec. 3800,Lab.C.). Policy Nc,. Company FOR APPLICANT TO FI LL IN BUILDING j�J' ADDRESS �j(Q G'n Certified copy is hereby furnished. BUILDIN ADDRESS LI r LOCALITY Certified copy is filed with the county building inspection OCALIT❑ r/�� AL,— /► NEAREST.department. P/ VVv (1 CROSS ST. ' Date Applicant NEAREST DISTRICT NO. G�FFFF3333QQQQUP TYPE PR ESSED BY CROSS 'D� � CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I 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 y so as to become subject to the Workers' Compensation Laws. MAIL / ) -� OCCUPANCY GROUP /,J(/_J a o ADDRESS Gv; `-lid-� ' /�' Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. / — OCCUPANT LOAD N Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: _ With comply With such provisions or this permit shall be TRAILER USE ❑' GEOLOGY INSPECTION•❑ NO Spec. Know]. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING ft� SPACES REQ'D E:= PROVIDED O � License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM: TD: 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). FINAL APPROVAL �� PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS €-_E, F hED ON LOT AND USE I hereby affirm that I am exempt from the Contractor's 0 1 v License Law for the,following reason (Section 7031.5, Busi- ness usi ness and Professions NO : . PARKING Code) I, as owner of the property, will do the work and the SPACES PROVIDED AN :09 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 aVplication and state that the PERMIT FEE oO 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 4'O upon th ove-me tione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE f� L Signature of Permi ee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION - CE 875 I:hereby affirrq that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, ora certificate of Workers'Compensation Insurance,or a certified cojlbl thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN BUILDING GO ADDRESS Certified Copy is hereby furnished. A ILDINDRESI ,0 �/ LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. I CROSS ST. Date Applicant AREST DISTRICT NO. GROUP TYPE PROCESSED BY ROSS ST. I� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP 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 d I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.h�� permit is issued, I shall not employ any person in any manner •OWNER i Vt*- i y so as to become subject to the Worker's' Compensation Laws. MAIL OCCUPANCY GROUP o #DDR ESS I-- Date Applicant I„ NOTICE TO APPLICANT: If, after making this Certificate of TY2" C ay N ` O 3� ) OCCUPANT LOAD N Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION El 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 PERMIT E] (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 rC effect. f� G✓J • PARKING REQ'D PROVIDED L SPACES License Number Lie. Class \ • LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: TO: INSPECTOR'S licensed architect or a registered professional engineer SIZE OF NO. OF acting in my professional capacity (Section 7051, Bus- RIES BLDG. STORIES s ATURE iness and Professions Code). FINAL APPROVAL Lie.or Reg.No. Date RESENT USE OF BUILDING ' _ HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUIL ING ON LOT AND USE I�\I(`J\/I % (�??i„•.—(i3_I!i :E;{ i',l'+ 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 s 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 1 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY k4OPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is kftA*XA &t issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address A v 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 upon the above-mentioned roperty for inspectio purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign re of Pernfittee Date ' WORKERS'COMPENSATION DECLARATION CE 875 M ISCELL_ANEOUS APPLICATION CE 875 (11-84) 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.). g Policy No.-- Company FOR APPLICANT TO FILL IN BUILDING ADDRESS /��*� FICertified copy is hereby furnished. X ADI RES_ 9� ° s ulvS Vv V . GLr LOCALITY Certified copy is filed with the county building inspection-- LOCALITY NEAREST department. XX CROSS ST. Date _-._Applicant---_. _ NEAREST DISTRICT G OU,� ITYPE CESSED BY CROSS ST. I D J/ — % CONS CERTIFICATE OF EXEMPTION FROM WORKERS' c LEGALa T COMPENSATION INSURANCE, DESCRIPT ION LOT NO. BLOCK MAP HIC Hw AY No. (CIRCLE) STATE MAJOR SECOND LOCAL rN OOF LDG_. (This section need not be completed if the work involved TRACT OW. ONBLOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) SE OFSIZE OF LOT XISTING BLDG. I certify that in the performance of the work for whichieya permit is issued, I shall not employ any person in any ma O NER of buildin We/sc, as to become subject to the Workers' Compensation L �/� /,/1 //�� /� OCCUPANCY GROUP MAIL /4/ 4 - U1 e-/% 4 � `e JL� C' ADORES Datc_�-_---- Applicant — — LL NO"I"ICF TO APPLICANT: If, after making this Certificate of CITY S�� C?�6rj No��/ Q� '73� OCCUPANT LOAD f:xempt'on, you should be_come 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. LICINSI:U CONLRACTORS DECLARATION OCCUPANCY INSPECTION E--- Panic Devices I hereby affirin that I am licensed tinder provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the BEx ' NO. OF EXITS ness and Professions Code, and my license is in full forceeffect. me of business PARKING / SPACES REO'D � PROVIDED O License Number Lic. Class Gtt fk�E 5 C��t e^r � o LIMITED TIME USE Contractor_____— Date DATE DATE I am exempt from the licensing requirements as I am a —0— ro: licensed architect or a registered professional engineer SIZE OF NO OF INSPECTOR'S acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg. No._ _ Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �✓ �� ON LOT AND USE I hereby affirm that I am exempt from the Contractor's "(/// License Law for the following reason (Section 7031.5, Busi- ness and Professions(.Ude): 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 BUILDING 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.C.). Lender's Name I I PROPOSED MAx 1 9;C C. Lender's Address_.-.--_---_ _ PERMIT FEE certif:v that l have read this application and state that the 25 .00 above information is correct. I agree to comply with all County ISSUANCE FEE rl ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25 .00 _.. e above-mentioned property for inspection purposes. XX XX / J 3 SEE REVERSE FOR EXPLANATORY LANGUAGE' �lw nl Pcrmittrr 0:11v .. '"WORKERS'COMPENSATION DECLARATION 75M444 MISCELLANEOUS A P P L I C A T I O N I hereby affirm that I have a certificate of consent self CE 875 (11-84)COU TY F 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 . OR APPLICANT TO FILL IN BUILDING ADDRESS D Certified copy is hereby furnished. 01 BUILDIN �1 DDR ESS Y LO CA LITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. ti CROSS ST. �J Date Applicant I NEAREST `u ♦ DISTRICT NO. GROUP TYPE O ESSED BY CROSS ST. EIVC / r `,I a.—CONSIV / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP �`q �� HIGHWAY No.`5-t0>_2,U (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT Ll (� 5 NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF Z/ } I certify that in the performance of the work for which this e SIZE OF LOT EXISTING BLDG. o 40 permit is issued, I shall not employ any person in any manner OWNER EVA `. so as to become subject to the Workers' Compensation Laws. AIL C C A d ° is OCCUPANCY GROUP014 ADDRESS 3 / S�(i 'I��A ,� ` . .� '.2 O Date Applicant C_� LLI NOTICE TO APPLICANT: If, after making this Certificate of &00CITY NO. LOAD l Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: _ with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ 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 EJ (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� effect. PARKING REp�D I I PROVIDED - SPACES License Number Lic. Class 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 SI ATURE iness and Professions Code). S� n FINAL APPROVAL E a Lic.or Reg.No. Date PRESENT USE: OF BUILDING LE ^ 9NO-T-S 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). ;25950A CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I► d,OLC I hereby affirm that there is a construction lending agency O. �� s&`E Q C # ° ° ° 8 8 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). o o ° o 0 0 o z Lender's Name PROPOSED MAX. OCC. 1 1,.1 7j86 Lender's-Address I certify that I have read this application and state that the PERMIT FEE above information is correct.I agree to comply with all County ISSUANCE FEE ord' ances and State laws relating to building construction, an hereby authorize representatives of thi County to enter TOTAL FEE u on the above-mentioned property for insp ction purposes. O+'" 12 I�,SEE.RI%vERSE FOR EXPLANATORY LANGUAGE OF (� ignatur f Pe itte Date WORKERS'COMPENSATION DECLARATION a CE 875 (11-84) MISCELLANEOUS APPLICATION CE 87 I herebOr certificate that 1 have a certificate of consent to self' COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insue, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No.T_Company FOR APPLICANT TO FILL IN BUILDING ADDRESS C/VLl Q6 Certificd copy-,is hereby furnished. rBUILDING LOCALITY f L c) LAS ADDRESS 0 Certified copy is filed with the county building inspection OCALITY NEAREST department. ( CRoss ST. Date Applicant NEAREST DIST ICTNO. GROUP TYPE / PROCESSED BY CROSS ST. . �� CONST. Y CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK rN Hlc Hw nY S (CIRCLE) STATE MAJOR SECOND LOCAL NO, OF BLOCS. (This section need not be completed if the work involved TRACT NOW ON LOT ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF rADDRESS E OF LOT EXISTING BLDG. _�. d /I certify that in the performance of the work for which this e o permit is issued, I shall not employ any person in any manner NER I (� y so as to become subject to the Wor ers' Comp ensa i n Laws. IL /+� j OCCUPANCY GROUP o ---�7 �,�n pp v U ' C~1Date 290hpplicant ,,, �� TEL. OCCUPANT LOADNOTICE TO APPLICANT: If, after making this Certificate of Y CQ No. � Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. 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 LNIL� IN Ui— effect. PARKINGSPACES REQ'D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date EAqDATE 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- ISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL J PRESENT USE OF BUILDING Lic.or Reg.No. Date �/% /,/&, /A--- HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 1� FEE 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 8/ 3/89 SPACES PROVIDED ❑ I, as owner of the property, will do the work and the4078 1 PPS ¢:50 structure is not intended or offered for sale (Section 7044,Business and Professions Code). 14 CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. Lender's Name t PROPOSED MAX. OCC. � Lender's Address � PERMIT FEE (=V5. . 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, d hereby authorize representatives of this County to enter TOTAL FEE on the �ovee--mnent�ioned/�r�operty for inspection purposes. I`,,lt/Cs SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date