HomeMy Public PortalAbout9669 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 'MISCELLANEOUS APPLICATION
CE 875(11-84) O`/� fl
I hereby affirm.that I have a certificate of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure;�pr a certificate of Workers'Compensation Insurance,or
a cer'tifled copy thereof(Sec.3800,Lab.Q.
BUILDING
Policy No. Company FOR APPLICANT TO FILL IN ^ '
ADDRESS069 V
Certified copy is hereby NGql `
DDRESS ALITY
Certified copy is filed with the county building inspection fOCALITY C,A /7
RAREST
department. CROSS ST.
Date .Applicant 0AuAREST DISTRICT NO GPO 5 CONST. P ES$ED
>.CROSS ST. ` ITYPE
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESP EiC1AL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
iTRAIL.ER
IZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this CD
permit is issued,I shall not employ any person in any mannerWNER
so as to become subject to the Workers' Compensation Laws. / /%� ®j �'y�/I CCUPANCY GROUPAIL °C
DDRESS (/ / ` I-_ P ��off ODate Applicant 7 LNOTICE TO APPLICANT: If,after.making this Certificate of ,TY � G T NO�. "� 6j OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPA CATI EXIT HARDWARE:Compensation provisions of the Labor Code,you must forth-with comply with such provisions or this permit shall be USE El INSPECTION No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi NO. OF EXITS
ness and Professions Code,and my license is in full force and '
effect. PARKING SPACES REQ'D PROVIDED
License Number Lic. Class
_ LIMITED TIME USE
-Contractor Date GATE GATE
❑ I am exempt from the licensing requirements as I am a /J IM-Al uJA4J&_
licensed architect or a registered professional engineer slzE of NO. OR FROM: To: INSPECTOR'S
acting in my professional capacity (Section 7051, Blas- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date RESENT USE OF BUILDING 1,-)0V1&&
-7a% Z— 4,65 7'C1/WK1 L1 u9
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, Busii8]I FEE
ness and Professions Code): NO. PARKING
El1, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section GWO_coo j 9/15/089
7044,Business and Professions Code). gy�pp// I 6I�
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 5745 L PM 4:48
I hereby affirm that there is a construction lending agency — ' Z— ( f7
for the performance of the work for which this permit is r1'
issued(Sec.3097,Civ.C.). G/f
Lender's Name �
i PROPOSED MAX. OCC.
Lender's Address 1
PERMIT FEE 100 '
I certify that I have read this application and state that the
above i4formation 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
pr "ab' '-mentioned property for inspection purposes.
^ 9 SEE'REVERSE FOR EXPLANATORY LANGUAGE
v aLv �3 8
Signa a of Permittee Date
I
um COMPENSATION DECLARATION , CE 875(11-84)a MISCELLANEOUS APPLICATION
CE 87
I wd�iiim that I have a certificate of consent tself'
ertificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
in or a c
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BADDREUILDING L• G 7 J
SS
❑ Certified copy is hereby furnished. BUILDING — DY
ADDRESS 66,1 /-,A!5 G �P$ LOCALITY
0 Certified copy is filed with the county building inspection
department. LOCALITY �.� •/'�-�j � �/�21 NEAREST
1. �O UVJ CROSS ST.
Date Applicant NEAREST ( r� ��N �,_ n DISTRICT NO. GROU TYPE
PROC E55ED BY
CROSS ST. �'f l�� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 6-�
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SEC D 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 I
SIZE OF LOT EXISTING BLDG. d
I certify that in the performance of the work for which thisCD
permit is issued, I shall not employ any person in any manner OWNER .— J7/Ip I, ZVC . =-'
so as to become subject to the Workers' Compensation Laws. / / _CI _ OCCUPANCY GROUP f =
�MAILIV ADDRESS �I7V 9 LS rtit7i1 31r'
Date Applicant Lam,I
NOTICE TO APPLICANT: If, after making this Certificate of CITY �� C�� No�' 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 ❑ GEOLOGY INSPECTION ElNo Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that.1 am licensed under provisions of Chapter SAFETY PERMI ❑ (LIST ITEMS BELOW) 1
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 REq'D D PROVIDED
SPACES
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 profbssional 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
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
2e5rU X87&9A
HOME OWNER-BUILDER DECLARATION NO. OF EXISUSE # O O O a 8 8TING BUILDINGS
I hereby affirm that I am exempt from the Contractor's ON LOT AND
License Law for the following reason (Section 7031.5, Busi- o o D o a.o D z
ness and Professions Code): NO. PARKING
El I, as owner of the property, will do the work and the SPACES PROVIDED
5 8 8
structure is not intended or offered for sale (Section 0
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency -eS'fCt
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
I certify tliat I have read this application and state that the PERMIT FEE Q�
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 VV
Pon the above-mentioned o erty for inspection purposes.
�
� i//O r� SEE REVERSE FOR EXPLANATORY LANGUAGE
' U
Signature of Permittee U Date
I
\ Al
�S'COMPENSATION DECLARATION 76M444It, MISCELLANEOUS APPLICATION P P L I C A'�I®l�!
CE 875 (1 1-84)
I here of um that i have a certificate of consent tc self ' COUNTY OF LOS ANGELES BUILDING ANIS SAFETY DIVISION
insure, c,*a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT'TO FILL IN BUILDING fes.
ADDRESS
Certified copy is hereby furnished. BUILDING 1 OCALITY
DDRESS ,L ,
DCertified copy is filed with the county building inspection V LOCALITY /` NEAREST
department. Q C 1 L. C CROSS ST.
Date Applicant NEAREST DIS CT GR I TYPE PROCESSED BY
C4/4
ROSS ST. S 711A1,45- //y yONs7
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL vUUUU
COMPENSATION INSURANCE DESCRIPTION • LOT NO.IX0
�- BLOCK MAP CIRCLE)No. CIRCLE)
STATE MAJOR SEGO LOCAL
(
,�y NO. OF BLDGS.
(This section need not be completed if the work involved TRACT 'Y n NOW ON LOT P111-oll
ZONE SPECIAL CO NDIT10 N5
by the permit is for one hundred dollars ($100) or less.) USE
of
SIZE OF LOT EXISTING BLDG � a
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 5zE s�
so as to become subject to the Workers' Compensation Laws. MAIL h OCCUPANCY GROUP o
ADDRESS V uzm L V
Date Applicant uJ
TEL .' OCCUPANT LOAD
NOTICE TO APPLICANT:.If,after making this Certificate of CITY .LN Si]•g y
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. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTIOPanic Devices
N
I hereby affirm that I am licensed under provisions of Chapter' I SAFETY PERM ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi i NO. OF EXITS
ness and Professions Code,and my license is in full force and, I�
effect. PARKING
SPACES REQ'D PROVIDED I
J
License Number Lic. Class
. LIMITED TIME USE
Contractor Date ' DATE DATE
0 I am exempt from the licensing requirements as I am a FROM. TD.
licensed architect or a registered professional engineer SIZE OF NO.CF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus-' EXISTING BLDG. STORIES SIG ATURE
iness and Professions Code).
Lic.or Reg.No. Date PRESENT USE OF BUILDING Q=_n5T4JFINAL APPROVAL
(S / z �9 O A
HOME OWNER-BUILDER DECLARATION No. OF
RX STING BUILDINGS
ON LOT ANI0 0 0 0 0 8
I hereby affirm that I am exempt from the Contractor's '0 o D o D O D co
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 SPACES PROVIDED ; 0 1„� 5`8 8
structure is not intended or offered for sale (Section
7044,Business and Professions Code). U
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDINGr
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 Addressp p�
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 here authorize representatives of this County to enter TOTAL FEE Q(�
u•on th a -m tioned roperty for inspection purposes.
p SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature f P ittee Date
WORKER$'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. �uILD1NG s
ADDRESS LOCALITY
dr-
Celrtified copy is filed with the county building inspection }.00ALITY NEAREST
department. � �� C(Z / ceoss sT.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE P ESSED BY
CROSS ST. , _� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL le
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAF HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF SLOGS.
(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 ��/��e'� �� o
permit is issued, I shall not employ any person in any manner %wNER �c L- :Et�� �' / _ /,i — i c>:
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
ADDRESS/'
1--`
Date Applicant p u�I
NOTICE TO APPLICANT: If,after making this Certificate of clrY� �6 NOL �'yJo�� _ 6 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 INSPECTIONNo Spec. ❑
deemed revoked. Knowl.
El
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION EI 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 I/
effect. PARKING REWD = pROVID ED
SPACES
License Number Lic. Class �!S CL�GtA^eP.�-E•
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 profbssional engineer SIZE OF NO.OF IN GN TOR E
acting in my professional capacity (Section 7051, Blas- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code).
Y �y
PRESENT USE OF BUILDFINAL APPROVALING
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 _ H.(.'7,?•i 1-JI, 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).
CONSTRUCTION LENDING AGENCY X 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
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL.FEE
upon the above-mentioned property fjr inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of rmittee Ibate
WORKER$'COMPENSATION DECLARATION 76M444
CE 875(11-84) M ISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insrire, or a certificate of Workers'Compensation Insurance,e,or '
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS (BUILDING /
�
ElCertified copy is hereby furnished. BUIRELDINSSG
ADD �� Tii�QS v� LOCALITY
Certified copy is filed with the county building inspection ), NEAREST
department. LocALlry :,p,4 le , C4 7e
CROSS ST.
Date Applicant NEAREST DISTRICT NOS) GROUP TYPE P CE35ED BY
CROSS ST. J .`�y �� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �/ (J
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP CIRCLE)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 - I fj I Ci
permit is issued, I shall not employ any person in any manner OWNER jp 4�LI�i/ J
so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP o
ADDRES 1--'
[�i�
Date Applicant 3 LULL
NOTICE TO APPLICANT: If, after making this Certificate of CITY e� i� TEL
NOTICE 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 ❑ ❑ No Spec. Knowl. El
p y P P TRAILER USE GEOLOGY INSPECTION
deemed revoked. occu PANcir INSPECTION ElI Panic Devices ElLICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi NO. OF EXITS
ness and Professions Code,and my license is in full force and /�
�(.i/i/,c� rJL�/br! PARKING I�
effect' . SPACES REQ'D PROVIDED �_ I
License Number Lic. Class � KICAQwl S_Z--Z4 —J
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).
,y
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No., Date 'f
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS P
h
ON LOT AND USE Vq,fl f
I hereby affirm that I am exempt from the Contractor's A,I"1 {EI 3113 ' Ii ``
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING /rI0 6768 1 AM 9-46
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).
PROPOSED 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.Q.
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-mentione property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Aram k
Signature of rmittee Date
W0;4iICERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I lureaffirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,, o or a certificate of Workers'Compensation Insurance,e,or �
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUDILDING l S
ADRESS
❑ Certified copy is hereby furnished. wcceessb6� Lis T//W p�
LOCALITY
❑ Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST. (
Date ApplicantNEAREST / DISTRICT O G O TYPE PROCESSED BY
ROSS ST. ) N �/ ^ /] �� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. CIRCLE)
STATE MAJOR SECOND LOCAL
(
NO. OF BLOGS.
(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
I certify that in the performance of the work for which this slzE OF LOT EXISTING BLD G. I O
permit is issued, I shall not employ any person in any manner OWNER 6F S� II AI&V — /✓C ''
so as to become subject to the Workers' Compensation Laws. MAIL (� M/�N OCCUPANCY GROUP a
�6Zy Z-44s T,NA-5 "
Date Applicant ADDRESS TEL. C ` La
8
NOTICE TO APPLICANT: If, after making this Certificate of CITY _ NO. ` ,, 16 OCCUPANT LOAD 9
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 PER ❑ (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. PARKINGREO'D O PROVIDED D
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 INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE
iness and Professions Code). /1
PRESENT USE OF BUILDING FINAL APPROVAL
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 Code): NO. PARKING
as owner of the property, will do the work and the SPACES PROVIDED❑ a o o 0 structure is not intended dr offered for sale (Section • I � $8
7044,Business and Professions Code). r o o a a o 0 0 z
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
11, 11 •=88
I hereby affirm that there .is a construction lending agency CJ1/A1.C—S- RLST/-1 lz/}/
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
PERMIT FEE rj,Op
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 by authorize representatives of this County to enter TOTAL FEE
u o the bove-merit! '
property for inspection purposes.
7- SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dated
I i '
i
WORKERS'COMPENSATIONDECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm thateI have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Wor':eys'Compensation Insurance,e,or
a certified copy thereof(Sec.3u'00,Lab.C.).
(1D D
Policy No. Company FOR APPLICANT TO FILL IN �UILDING
RESS
-1 Certified co is hereby furnished. BUILDING p� J
PY Y 66-/ Loi S (w Via S D V T
OCALITY
ADDRESS
0 Certified copy is filed with the county building inspection LOCALITY N
RAREST
department. ?� P C;C` FROss ST.
Date Applicant CROSS r f (DIST ICT NO. G OU CONST. PROC F„SSED BY
CROSS ST. r (/,C�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK �7AP (CIRcL ) STATE MAJOR SEC- LOCAL
O. (GIR CLE)
O. OF-BLD GS.
(This section need not be completed if the work involved TRACT OW ON LOT WE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) E v ISTIfG o
N
I certify that in the performance of the work for which this D_
permit is issued I shall not employ person in an manner o
P : P Y an Y P Y OWNER �qi�J.t FCL I S>
so as to become subject to the Workers' Compensation Laws. MAIL �1 /��,, OCCUPANCY GROUP 13�E
o
Date Applicant AD OR ESS C'(J�// /am I v �([ I W
SaAA( lb TEL. �I —S" I OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY a vi' No. y
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 oI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. ElE] No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ I Panic Devices
I hereby affirm that I am licensed under provisions of Chapter i 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.
F
effect. /!� C• r ✓�/ PARKING REO'D PROVIDED
SPACES
License Number Lic. Class I
LIMITED TIME USE
i
Contractor Date i DATE DATE
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer IZE OF �j" o.OF i
FROM: TO:
�� / I tNSPE 70 R'S
acting in my professional capacity (Section 7051, Bus- 'ZE LNG I.G.B1 TORIES SIG ATURE
iness and Professions Code).
i
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE p 0 1 Q 5 n
I hereby affirm that I am exempt from the Contractor's z J f1
'License Law for the following reason (Section 7031.5, Busi- # o D a o 3 0
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the ' SPACES PROVIDED I o 0 8 Q 5 0
structure is not intended or offered for sale (Section y
7044,Business and Professions Code). o o D 8.05 0 c1
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 0303"88
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
I certify that I have read this application and state that the PERMIT FEE �0,9-
above information is correct.I agree to comply with all County ISSUANCE FEF/,49 • 6
ordinances and State laws relating to building construction, .
and hereby authorize representatives of this County to enter TOTAL.FEE
u on the above-mentione perty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee (Date
WORKERS'COMPENSATION DECLARATIONI 76M444 I i ^
I CE 875(2-80) MISCELLANEOUS APPLICATION � t
I hereby affirm that I have certificate of consent self, COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION '
insure,or a certificate of Workers'Compensation Insurance,e,orl I I�
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company I FOR APPLICANT TO FILL IN BUILDING P t
❑ _ ADDRESS � e I
Certified copy is hereby furnished. BUILDING 9 ■, ��77 I 1
❑ ADDRESS ! S /�/ LO ALITY a
Certified copy is filed with the county building inspection,' NEAREST �i VJ
department. LOCALITY �LL CROSS ST.
Date Applicant N REST DISTRIC JAI O. Get OyP TYPE JPR��Y Y
ROSS ST. 4 .Fr Jr(/fJVA(/ Ff/�'(//_ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAb HIGHWAY }
NO. OF DGS.
NOi (CIRCLE) STATE MAJOR S NO LOCAL 0L
(This section need not be completed if the work involved TRACT NOW ONBLLOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100).or less.) USE OF 1
siZk OF LOT EXISTING BLDG. _1
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 El-jI�1�� � G)A�/a D pl SN Co 1--
so as to become subject to the Workers' Compensation Laws. IL I OCCUPANCY GROUP LU
ADDRESS 420 W W 1S7Ce414 -/1(/r•
Date Applicant IL
NOTICE TO APPLICANT: If, after making this Certificate of Irv919 A- � o-ioL 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
deemed revoked. ❑ No Spec. Know,.
OCCUPANCY INSPECTION Panic Devices
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions Of Chapter; SAFETY PERMIT Q (LIST ITEMS BELOW) I 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
aPAIC ES REQ'D PROVIDED
License Number- Lic.Class i
LIMITED TIME USE
Contractor Date I DATE DATE
❑ FROM: TO:
I am exempt from the licensing requirements as I am al
licensed architect or'a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting'in my professional capacity (Section 7051, Bus] EXISTING BLDG. STORIES I SICINATURE
iness and Professions Code). i FINAL APPROVAL
SENT USE OF BUILDING 0
0 GALS
Lic.or Reg.No. Date /T y
' Foal of B 87/.
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
❑ I, as owner of the property, will do the work and the I
structure is not intended or offered for sale (Section 234 9, 1 A
7044, Business and Professions Code).
-POSED USE OF BUILDING 0 0 0 0 8 8
CONSTRUCTION LENDING AGENCY V
I hereby affirm that there is a construction lending agency' S'4/1r Ya 0 D 4-69'V, \�� ' 0 0 o D o 0 o z
for the performance of the work for which this permit is OJ1
issued(Sec. 3097,Civ.C.). I J „l 8 $ rJ
Lender's Name PROPOSED MAX. OCC. I
I ,
Lender's Address I
PERMIT FEE
I certify that 1 have read this application and state that the, ISSUANCE FEE
above information is correct.I agree to comply with all County;
ordinances and State laws relating to building construction,, TOTAL FEE
and hereby authorize representatives of this Cou •y to enter,
pon , eabove-mentioned property for inspe n purposes., SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION CE 875(2-80) M I S C E L LA N E®USI APPLICATION
I hereby affirm that I have a certificate of consent to self I COUN'T'Y OF LOS ANGELES BUILDING AND SAFE'T'Y DIVISION
insure, or a certificate of Workers'Compensation Insurance,or I
a-certified wJpy thereof(Sec.3800,Lab.C.)
muiLDING
Policy No. Company FOR APPLICANT TO FILL IN AD
RESS �`..
I
❑ Certified copy is hereby furnished. t'• jwucR=sG LOIIALITY
❑ Certified copy is filed with the county building inspection i.
NEAREST
'department. ILO CALITY'1 CROSS ST:
Date Applicant 'NEAREST DISTRICT NO/// SUP
Y E PROC SED�BY
)CROSS ST. Q ,1 CONST. r
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. (i BLOCK MA p HIGHWAY
NO.I DIO (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OR SLOGS.
(This section need not be completed if the work involvedNOW ON LOT(TRACT US •ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of O
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this . 1s W
permit is issued, I shall not employ any person in any manner IOWNER /
lleso as to become subject to the Workers' Compensation Laws, ; 'OCCUPANCY GROUP W
(MAIL
IADDRESS 60 J A a
Date Applicant TEL. U).
NOTICE TO APPLICANT: If, after making this Certificate of L(CITY No. I OCCUPANT LOAD 1_ � 2
Exemption, you should become subject to the Workers' APPLICATION FOR i 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. ❑ Cl No Spec. Knowl. ❑
' Panic Devices ❑
LICENSED CONTRACTORS DECLARATION occuPwrvcY INSPECTIorv, i
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
I PARKING-
effect. SPACES REQ'D'� PROVIDED
License Number Lic.Class ' LIMITED TIME USE
Contractor DateI DATE DATE
❑ F RO'M: TO:
I am exempt from the a
licensing requirements as I am
licensed architect or a registered'professional engineer ISIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES i SIGNATURE
iness and Professions Code). FINAL APPROVAL '
V',PRESENT USE OF BUILDING I �.+"��. •� r;a ,yy�
ll.••!s!"
Lic.or Reg.No. Date e
'NO.OF EXISTING BUILDINGS
HOME OWNER-BUILDER DECLARATION I
ON LOT ANO USE I
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): SPACES P OVIDED 2.1 1 3 0 A
❑ I, as owner of the property, will do the. work and the J #,0 0 0 0
structure is not intended or offered for sale (Section
8.8
7044, Business and Professions Code). _ J
PROPOSED USE OF BUILDING I OIO O O 0.0 O
CONSTRUCTION LENDING AGENCY / I ;
I hereby affirm that there is a construction lending agency /` a� I 09, 1 ,1 —8 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 Sta to building construction, ~
and hereby au ori ze sentative of this County to enter TOTAL F �
up4thab mentione pr forinspection rp ses. (SEE REVERSE FOR EXPLANATORY LANGUAGEe of Permittee D e
WORKERS'COMPENSATION DECLARATION CE 875(11-84) M I SC E L LA N EO U S APPLICATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified cop thereof(Sec. 3800,Lab.C.).
Policy No. I Company FOR APPLICANT TO FILL IN BUILDING /_
ADDRESS (Q I J IV
EI.Certified-copy is hereby furnished. N UILDING
a ADDRESS //.� .� LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
depaztmenAl - CROSS ST.
Date .c7L ApplicantEAREST DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP MI.—Ay
NOOF LOGS. STATE MAJOR SECOND LOCAL
, (CIRCLE).
(This section need not be completed if the work involved TRACT NOW ONBLOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
CD
I certify that in the performance of the work for which this SIZE of LOT EXISTING BLDG. Q>
LAJ
permit is issued, I shall not employ any person in any manner " 'OWNER .=!
so as to become subject to the Workers' Compensation Laws. / AIL ) OCCUPANCY GROUP
ADDRESS f ✓ A) .* ,`'� >
Date Applicant _ L. C+ a
NOTICE TO APPLICANT: If, after making this Certificate of c, �� NO. OCCUPANT LOAD �'
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: a-
Compensation provisions or the Labor Code, you must forth- ❑
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION
ElNo Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect.
1 f J �; PARKINsPACEsG REQ'D PROVIDED
_
License Number Lic. Class LIMITED TIME USE
Corltractor Date - DATE DATE
El 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 SIGNATURE
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date RESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE l
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness
usi 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). ,
•• } � W
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 D,
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
rdinances and State laws relating to building construction, F 4J
d hereby authorize representatives of this County to enter TOTAL. FEE Z
on the above-mentioned property for inspection purposes. _
SEE REVERSE FOR EXPLANATORY LANGUAGE 9�
l i
Signature of Permittee Date
\\'ORKLIZS'COAIPLNSATION DECLARATION I CE 875(77-84) M ISCELLANEOUS APPLICATION 'fl
lierel;'y affirm that [ have a certificate of consent to selfCOUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
,insure, c:• a certificate of Workers'Compensation Insurance,or
' a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN wooRess J ( A,5
i
1:1Certified copy is hereby furnished. XX nUILDINDDRESS 6C-1 S . 'y LOCALITY gy.� Q.
Certified copy is filed with the county building inspection LOCALITY +� ` �` j NEAREST
department. yy. 1e 1 t cR Oss ST.
Date —Applicant NEAREST DISTR CT NO. GR/O�UP CONST. P ESSED BY
CROSS ST. J�� /�
CERTIFICATE OF EXEMPTION FROM WORKERS' P LEGAL V 12 !!!
COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF SLOGS.
(Tills 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
I certify that in lite performance of the work for which this SIZE OF LOT EXISTING BLDG.
permit is issued, 1 shall not employ any person in any mannelSEX OWNER Of buildin a LD)4 VJPrN ® o
stl as to become subject to the Workers Compensation Laws. MAIL OCCUPANCY GROUP c
ADDRESS t MdC:
Dale_ —Applicant LL
TEL. OCCUPANT LOAD u.
NOTICl-TO APPLICANT: If,after making this Certificate of CITY o. o
Exemption, you should become subject to the Workers APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must fo'rth-
with comply with such provisions or this permit shall be TRAILER USE[] GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION ' occurwNcr 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 B�usi-X
No. of Exlrs
ness and Professions Code,and my license is in full force an
effect. Name Of business PARKING REO'D PROVIDED
SPACES
License Number Lic. Class I LIMITED TIME USE
t
Contractor— Date
DATE DATE
FROM: TO:
El1 am exempt from the licensing requirements as I ap a INSPECTOR'S
licensed architect or a registered professional engineer SIZE OF NO.OF GNATURE
acting in my professional capacity (Section 7051, Bus' EXISTING BLDG. STORIES N—1 ' IF E'- .
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS Q /a `i ff +i i+=i•+
ON LOT AND USE
I hereby affirm that 1 am exempt from the Contractor's
License Law for lite 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 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 ,
PROPOSED MAX OCC. 1
Lender's Address—_— - —
PERMIT FEE 25.00
I certify that I have read this application and state thab the
above information is correct. I agree to comply will'all Coiinty ISSUANCE FEE
+ ordinances and State laces relating to building construci'ion,
and hereby authorize representatives of this County to enter I TOTAL FEE 25.00
upon(lie ab oiled pro erty fqr inspection purposes.
1 � I ( SEE REVERSE FOR EXPLANATORY LANGUAGE
t XX XX ._ = 4
I'rnnillry hate
WURKhK54lJIVIrCIVJA1IuI4 utLLAKAl1UIV 20-0063DPW12/90 IlrllI Vr+1L,L..HINGVu lei Li—I-"1L.rL.H1 IVl11 ,
I hereby affir(n 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 =vpy thereof(Sec.3800, Lab.Q
Policy No. Company FOR APPLICANT TO FILL IN BUILDING /
BUILOIN ADDRESS _� ADDRESS ( -
® Certified copy is hereby furnished. 'J, Lyrl dr.� LOCALITY
Certified copy is filed with the county building inspection CIUL
CeZIP` NEAREST
department. _.;,7�, O l9 CROSS ST
Date Applicant SIZE oF' OT NO.OF BLDGS.NOW ON LOT DISTRICT NO. 1.GRO P TYPE P SSED BY
CERTIFICATE OF EXEMPTION FROM WORKERS' I D� CONST.
COMPENSATION INSURANCE Tr ACT BLOCK LOT NO.
I MAP HIGHWAY
• NO. (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved A SESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
by-the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this OWNER • • L N n
permit is issued,•I shall not employ any person in any manner property 1/ �e±Az—& -
so as to become subject to the Workers' Compensation Laws ADD Ss
J P OCCUPANCY GROUP
Ay
Date Applicant CITY_ ZIP
' OTICE TO APPLICANT: If, after making this Certificate I 3 2 OCCUPANT LOAD
I61'' P APPLICATION FOR
.of Exein tion; you should become subject to.the Workers' EXIT HARDWARE:
Compensation provisions of the Labor Code,yod must forthwith
comply with'such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑
. revoked. E] �
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM T❑ (LIST ITEMS BELOW)
h(commencing with Section 7000)of Division•3 of the Business NO.OF EXITS E
and Professions Code,and my license is in full force and effect. '
PARKING• REQ'D � PROVIDED D
License Number Lia Class '•' � SPACES_•
Contractor : Date LIMITED TIME USE
DATE DATE -
I am exempt from the licensing requirements as I am a I FROM: TO:
licensed architect or a registered professional engineer
acting in my professional capacity.(Section 7051,Business SIZE OF NO.OF )NSP ATURE
and Professions Code). EXISTING BLDG, STORIES
Lic.or Reg. No. Date PRESENT USE OF BUILDING FINAL APPROVAL
n.
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
• ON LOT AND USE
011•liereby affirm that I am exempt from the Contractor's License
. Law for the following reason (Section 7031.5, Business and I
`Professions Code): NOI PARKING
❑ I, as owner of theSPACES PROVIDED
property, will do the work and the
structure is not intended or offered for sale(Section 70447, PROPOSED USE OF BUILDING
Business and Professions Code).
i •
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
(Sea 3097,Civ.Q. l PROPOSED MAX.OCG
Lender's Name APPLICANT(PRINT) TEL NO.
Lender's Address ADDRESS
•I certify that I have read this application and state that the
'. above information is correct. I agree to comply with all County PERMIT FEE
ordinances and State laws relating to building construction,and I
hereby authorize representatives of this County to enter upon ISSUANCE FEE
the abo b-men io ed p aerty for inspection purposes. I1 i
TOT1i L FEE
lvw 0 SEE REVERSE FOR EXPLANATORY LANGUAGE i
(/ I re ofTermittee Date
ry