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R'4RI:L-RS'CO;%IPENSaT10N DECLARATION i 78U1444 I M ISCELLANEOI S APPLICATION
CE 875 111-84) .�
[ hereby affirm that I have a certificate of consent to c 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.1. I
Policy No. _Company FOR APPLICANT TO FILL IN IBUILDING
IA DORESS
Certified copy is hereby furnished. BUILDING
i ADDRESS u� ,� ILO CA LITY 1_/L -�
1 Certified copy is filed with the count, building inspection _ LOCALITY NEAREST !moi"+
department. Temple City c1:o IS ST.
Date .applicant NEAREST DISTRICT NO. GR P TYPE P CESSED BY
• CROSS ST. r> CONS
CERTIFICATE OF EXEMPTION F_RO11 WORKERS' LEGAL ' �d .__100I COMPENSATION INSLRANCL• I DESCRIPTION LOT NO. (BLOCK !1MAP HIGHWAY
• jry 0. STATE MAJOR SECOND LOCAL
nvI NO. OF SLOGS. (eIa CLE(
(This section need not he completed If the work involved -RACT NOW ON LOTJU SE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars 61001 or less.)
USXISTING BLDG.
E OF
I SIZE OF LOT EIj
1 certify that in the performance of :he .t,�r4 ,or bleb -his �-�•
permit is issued. I shall not emplo% any aercon :n any manner "�F� G� SAN U EL-05 �
so as to become cubiect :o the Workers' Compensation I_awc• MAILt TA A OCCUPANCY GROUP I�
1 ADORE
I Date Sr Applicant �
NOTICE TO APPLICANT: If. ;tater making :his Cert,' -It�$I CIT" . (W �
LE •P` OCCUPAN—LOAC
Exemptio•t, you diould become subject -o -lie Workers'
Compensation provisions of the Labor i.,)de. you must
torch-with compo• with such nrovWons or :his ^ertnir Shall be I -RAILER USE I� GEOLOGY :NSPECTICN � NO SoeC. K lot^JI•
deemed-evoked.
N
LICENSED CONTRACTORS DECLARATION � OCCUPANCY INSPECTION$ Panic Devices
=' I hereby affirm :(tat 1 am licensed under provisions of Chapter —
SAFETY PER IT (LIST ITEMS BELOW)
9 tcomntencinE with Section "0001 of Division 3 �i alae Busi- NO. OF EXITS
ness and Professions Code.and m} license is in fail force and \\\
effect. Ai' TLr�-• PARKING
'SP.CES REO'O O PROVIDED
License Number Lic. Class
LIMITED TIME USE
y Contractor Date I DATE DATE
W
I am exempt from the licensing requirements as I am .l I°q�M- TO:
1 licensed-arch1U:CI-0.0 —i-eZ3SLCLPd—pinI�SC10Jtal—.RSI neEr -SITE-O pF `-INSPECTOR'S
z acting in ;m• professional :ar'acit.. se::ion ..Il: 1. BUG- EXISTING BLDG. 3TORIES SIGNATURE
a iness and Protessicns Cade I. _ -- ;tr—� �� t t��
:J ' PRESENT USE OF BUILDING (NAL APPROVAL t'•7 —
$ Lic.or Reg. NIS. Date
x 1 �.
HOME 011•N1 R-BUILDER DECLAR.mON NO. OF EXISTING BUILDINGS V �97��
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason I Section -!131.5. Busi-
ness and Professions Codec: I NO. PARKING
EJ1, as owner of tate property. will do the work and the SPACES PROVIDED ;
structure is not intended or offered for Bile (Section J
7044.Business and Professions Codel.
I
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending ;ipcnLv l� gcx%n
for the performance of the work for which this permit is
issued ISee.3647.Civ.C.1. I IS ckjh t C Ii
Lender's Name I
! PROPOSED MAX. OCG.
Lender's Address _ )
I I certify that I have read this application and state that the PERMIT FEE 25.00
above information is correct.I agree to comply with all County 1 ISSUANCE FEE I
ordinances and State laws relating to building construction.
and hereby authorize representatives of this County to enter i TOTAL FEE 25.00
� i I• upon t! •above-mentioned pro crty for jnspecti n purposes. �
1 9 SEE REVERSE FOR EXPLANATORY LANGUAGE j
� I Signature of Permit ee� � '�a� ���1