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76M444-DBS 75 11-55 �. MISCELLANEOUS- APPLICATIOI 1
.DIVxS,0N OF BUILDING AND SAFETY OCCUPANCY-SAFETY-TRAILERS
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS L-
CASSATT D GRIFFIN,SUPT OF BUILDING LOCALITY 7e/711-11p� Crt�v
FOR APPLICANT TO FILL IN NEAREST
OWNER !
J S CROSS ST. es G�
ADDRESS 1�� p ` `, ICS N GROUP I TYPE OyONST.
C' TEL!e$ U 4 +
CITY Cf .r! NO.. MAP V f STATE YES NO J
TEL. NUMBER (J HWY
CONTRACTOR NO. USEZONE SPECIAL
ADDRESS CONDITIONS
/gyp-�J�
LEGAL I LOT NO. I BLOCK EXIST.
DESCRIPTION BUILDING/ON W
SETBACK YARDI HY I STREET NAME I WIDTH
NO OF
TRACT (t� I NOW ON L TS FRONT
P L.
USE OF SIDE
SIZE OF LOT EXISTING BLDG. P L
APPLICATION FOR INSPECTION RECORD
OCCUPANCY
INSPECTION SAFETY PERMIT
TRAILER USE I LIMITEDTIME USE
DATE DATE
FROM' TO:
USE OF STRUCTURES OR DEVICES
INSPECTION FORD
OCCUPANCY AS
APPROVALS
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS DATE INSPECTOR'S SIGNATURE
APPLICATION AND STATE THAT THE ABOVE IS CORRECT
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES OCCUPANCY APPROVAL
AND STATE LAWS REGULATING BUIL G NS RUC- GROUP OCC.LOAD
TION
SIGNATURE OF �" TRAILER USE
PFf2MITTEE 1
SAFETY PERMIT
ADDRE
TEMPORARY
STRUCTURE APPROVED
TEMPORARY
STRUCTURE REMOVED
FEE$
f FINAL APPROVAL
JOHN A. LAMBIE. COUNTY ENGINEER. ATION CLYDE N. DIRLAM.CHIEF BLDG. INSPECTOR
CK MO CASH
�ht,o 2 2 2 E YAY 2 3 2 2 D 1 5.0 0
110KKLKS COMPENSATION DECLARATION 76M444
(11 84)
CE 875 MISCELLANEOUS APPLICATION
1 hereby affirm that ( 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 CBUILDING
)
Policy No Company FOR APPLICANT TO FILL IN ADORESS
FICertiliea copy is hereby furnishedXl' BUILDING L�� LCCALITY
DR Ess
Certified copy is filed with the county building inspection LOCALITY NISAREST
department yy. CnO99 ST
Date_ __— \DpiL int NEAREST D19TR1 T NO GROUP TYPE P c59EO BY
CROSS STD� CONST
( I•R I If I('\FE OF E\E`1PTION FROM WORKERS' LEGAL
CO\1PE\S\TION INSURANCE DESCRIPT70N LOT NO BLOCK MAP cww r
NC (CIR G L.) STATE MAJOR SECOND LOCAL
NO OF BLOGS
(Ilii, �ectmn heed not be com Dleted if the 'cork involved TRACT NOW ON LOT U!•E :ONE SPECIAL CONDITIONS
ov the penult Is for one hundred dollars (5100) or less) I USEOF
SIZE OF LOT EX Is TING BLDG G
I �e'nn that m the performance of the fork for `.vetch ;his �---
pernut is Issued, I snall nut emplov any person In any manne%,[3{ NEA of building {� I
a, is to he(mlle sIlhjcL' `o (he Workers Compensation Laws MAIL OCCUP4NC/ GRCUP
ADDRESSCr L
NOFICi f0 ,APPLR \NT If, alte* makine this Certificate of =1TY� NOL \) y��q OCCUPANT LOAD °
I emotion, you should become subject to the Workers' I -
(onlpensatlon pnl�iswns of the Lauor Code you must forth- APPLICATION FOR EXIT HARDWARE
til cmmnls k%Jill quLll ilrU�isions or this permit shall be 'TRAILER USE ❑ GEOLOGY INSPEC-ION No Spec Knowl
Ill'_IIILd rC• Okt!d
I R I VSt 1)(ON i R\( 1 ORS DELL\RATION OCCUPANCY INSPECTION [f PantC Devices ❑
i
I llerehl ,ilfirin that I aril ('Lensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BE SOW I
Q (C0rinmenL1rrg with Section 7000) of Division 3 of the Bust ND OF EXITS
ness and Protcssions (,tie Ind ms license is to full force a
"�,X Uame of business I. RKING
� __�.. � ,� 9YACE9 REO'D � PROVIDE?
I IL'- I,r Number _ _ I IL (lass I�-(1\�� �-�111 � JI C�
- - - - LIMITED TIME USE
t I,nlrictl,r hate _
/aOM 'O
1 dill exempt tram the licensing requirements as I am a
NSPEC-OR s
17 licensed architect or a registered professional engineer SIZE OF NO OF
acting in my protessiunal capacity (Section 7051, Bus-
E<ISTING BLDG STORIES 51 ATURE
iilessandProt essiunsCode) F'NAL APPROVAL
I IL or RC2 N,1 _ _ _ _______ Date
PRESENT USE Of BUILDING /
110\11 OWNFR-BI'II-DER DECL\RATION NO OF EXISTING BUILDINGS 0
ON LOT AND USH 'll
I herchy affirm that I ,im exempt from the Contractor's
1 leense I aw for the Iolluwing relson (Section 7031 5, Busi-
ness
usyness .Ind Protessiom(_ode) NO PARKING s� -
SPACES PROVIDED
I
1 1, as owner of the prupert% ,rill do the work and the
structure is not intended or offered for sale (Section
7044, Business,inu Professions Code)
(ON')I RL-( 110N 1 LNDING kGENCI PROPOSED USH OF BUILDING
I hereby affirm that there is a construction lending agency I
lur the perfurmanLe of the work for which this permit is
issued(Sec 3097,Civ C)
I ender's Name—_--___ _ ___--
PROPOSED MAX OCC
1 ,ndcr s \ddress _ -__- _ -_ —
I Lertliy that I h.ne read this apphL.ition and stale that the PERMIT FEE
ahuve mlunn.ltion i%correct I agree to comply with all County ISSUANCE FEE
ordutanLes and Sla tans relating to building construction,
and herebv ai to a representatives of a County to enter 1 rOTAL FEE 25. QQ
- uprnl the�hho -j �rtuun �op �Io, eLhon purposes
r SEE REVERSE FOR EXPLANATORY LANGUAGE