HomeMy Public PortalAbout9414, 9412 LAS TUNAS DR_Miscellaneous__ WO,•RKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 875
I hereby affirm that I -have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insjrre, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab:C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS �-• ,. � `� 1
Certified copy is hereby furnished. Aooeess VC LOCALITY
0 Certified copy is filed with the county building inspection COCALITY ! NEAREST 1
department. CROSS ST.,
Date Applicant NEAREST f DISTRICT O. GFy�O UP 'TYPE IPR,,�CIESED BY
CROSS ST: /} •✓ C NST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �.
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY
rvo. (CIRCLE)
STATE MAJOR SECOND LOCAL
NO. OF'BLD G S.
(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 It of Lor ISTING BLDG. O
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. AIL _ _ /���J /y.�� OCCUPANCY GROUP a
ADDRESS .Z .S /jam �`TH I/ ! ~
Date Applicant � r w
NOTICE TO APPLICANT: If, after making this Certificate of Y CQ nC 1Tvo� gl� /fS-!� OCCUPANT LOAD
CITz
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 E] No Spec. Knowl.
deemed revoked.
LICENSEDCONTRACTORSDECLARATION OCCUPANCY INSPECTION ElPanic Devices E
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 REQ'D D PROVIDED
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
Ei 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- ISTING BLDG. STORIES 516 AruRE
E
iness and Professions Code).
PRESENT USE OF BUILDING �' C(� ��g"° FINAL APPROVAL
Lic.or Reg:NO. Date
HOME OWNER-BUILDER DECLARATION No. OF,EXISTING eu1LDlNcs
ON LOT ANO 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 Il�
DI, as owner of the property, will do the work and the SPACES PROVIDED I
structure is not intended or offered for sale (Section
7044,Business and Professions Code). _
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING i/Q 7 G 0CER4CS �8 8 2 0 A
# o0 88
I hereby affirm that there is a construction lending agency C(.. V I D 10 d-- 0 L � L
for the performance of the work for which this permit is a o ® e e.o o z
issued(Sec. 3097,Civ.Q. l(3` � N )/y(;
Lender's Name 0 1,22-88
' 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, D
and hereby authorize representatives of this County to enter TOTAL FEE
INIf on the above-mentioned property for inspection purposes. °
SEE.REVERSE FOR EXPLANATORY LANGUAGE
Signature of geTMittee 7Date
WORKERS'COMPENSATION DECLARATION 75(11-84)
CE 875 MISCELLANEOUS APPLICATION
CE 8
I hereby affirm that I have a certificate of consent to self COUNTY.OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or arcertificate of Workers'Compensation Insurance,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 �/ ,T'C LOCALITY G
ADDRESS
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. �� cRoss sr.
Date Applicant NEAREST „µ.����������,�.����//ppppy� i�P �q� ^Q �1 DIST
fCT/( O. GR UP TYPE PROCE D BY
PP CROSS ST. P& \lJ V„ Vim„ os�WY r� {�/j ( CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �J
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. - >67-
1 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 1%.f. `Yl'�`�<_Q_ ��� s'
so as to become subject to the W kers' Compensation Laws. MAIL OCCUPANCY GROUP/ o
Date o�9 , —Applicant , ADDRESS 9k'�y —_ �± AAA �
77" C� p,�TEL. W
NOTICE TO APPLICANT: If, after making t s Certificate o clr( L«O.NO. OCCUPANT LOAD N
Exemption, -you should become subject to the Workers'_ FOR EXIT HARDWARE: Z_
�-_Compensation-provisions•of-the-;Labor-Code;you-must fortfi= APPLICATION
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 ❑ (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 REQ'D E� PROVIDED
SPACES
License Number Lic. Class LIMITED TIME•USE
Contractor Date DATE DATE
' FROM: TO:
0 1 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- XISTING BLDG. STORIES SVGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING . LS FINAL APPROVAL
Lic.or Reg.No. Date UezaA U. J
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
,8.5
I, as owner of the property, will do the work and the SPACES PROVIDED ;g# o.o, 1,
o.o
structure is not intended or offered for sale (Section \ o o to'o o o.o
7044,Business and Professions Code). h\
CONSTRUCTION LENDING AGENCY . , PROPOSED USE OF BUILDING v,l
I hereby affirm that there is a construction lending agency '„ \�_ 12 D 6-8 7
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
up the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION CE 8754(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 'fl
a certified coplrthereof(Sec. 3800,Lab.C.). -31
Policy No. Company FOR APPLICANT TO FILL IN BUILDING p
�. _ ADDRESS
Certified copy is hereby furnished. BUILDING 941 LAS —�- S b9- LOCALITY l C
ADDRESS l�
❑ Certified copy is filed with the county building inspection LOCALITY NEAREST on N
department. CROSS ST.
Date Applicant NEAREST Com^ DIS _ R TYPE PR E E BY
K CROSS ST. OAK CJ 1 • CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) .STATE MAJOR S COND 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. d
I certify that in the performance of the work for which this
permit is issued, I,shall not employ an person in any manner �\� .,(� ��I �
P P Y Y P OWNER W�,�I L y
-so as to become subject to the Workers' Compensation Laws. L OCCUPANCY GROUP �
K MAIL p
C~7
Date Applicant ADDRESS WAS
TEL' OCCUPANT LOAD n
NOTICE TO APPLICANT: If, after making this Certificate of crcv r�MPLC NO.K cn
Exemption, you •should become subject to the Workers'
A - -- = — - —
—Compensation°provisions`of`the-Labbr Code,"you'must fortli-
PLICATION-FOR _� EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOG'' INSPECTION ❑ No Spec. Knowl.
deemed revoked. - - -.
----'OCCUPANCY INSPECTIONJ91 - -
Panic Devices
-- -- ,LICENSED CONTRACTORS-DECLARATION - v
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 /t/ �rlCi l�yIW
effect. �f PARKING REQ'D PROVIDED
SPACES
License Number Lie. Class GLavosaL f LIMITED TIME USE
Contractor Date - DATE DATE
DI am exempt from the licensing requirements as I am a FROM: TO: '
licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATU E
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No. Date 1'S
T ;,J l LI i g
HOMEOWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS @�� E
ON LOT AND 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): NO. PARKING 1 - 1 i 12/11/89
I, as owner of the property, will do the work and the SPACES PROVIDED 1 AM �.,8:2
!6
structure is not .intended or offered for sale (Section
7044,Business and Professions Code). /� /)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING TA I-/A '/�V DEL/
I hereby affirm that there is a.construction lending agency c)(P
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name 1
PROPOSED MAX. OCC. I 1
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 ate)
upon iabove-mentio d o erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
lt�L�t�
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION 76M444 SC.E L LA N EO U S APPLICATION
' • CE 875,01-84)
I hereby affirrp that I 'have a certificate of consent to self F t
insure"or a certificate of Workers'Compensation Insurance,or COUNTY Oi• - ANOtLES BUILDING AND SAFETY DIVISION u
a certified copy thereof(Sec. 3800,Lab.C.). ,
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING �/Ty _ lL�
ADDRESS
Certified ADDRSS LCALITY
ied copy is,hereby furnished. BUILDEING I
O_� •^
Certified copy is filed with the county building inspection LocnLlry
q/ NEAREST
department. rI` - ceoss ST.
Date Applicant NEAREST DISTRICT NO. GROUPTYPE p CESSED BY
CROSS ST. k D _ �I CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' ' LEGAL o o�
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLocX MAP HIGHWAY
r NO. (CIRCLE) STATE MAJOR SECOND LOCAL
IND OF BLDGS.'
(This section need not be completed If the work involved TRACT NOW ON LOT USE E S
ZONPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) use of
SIZE OF LOT EXISTING BLDG. C/1
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 �
so as to become subject to the Workers' Compensation Laws. � MAIL y OCCUPANCY GROUP ADDRESS DI - I.—
Date Applicant
TEL: OCCUPANT LOAD _ O-•
NOTICE TO APPLICANT:•If, after making this Certificate of �; CITY 7.e -04 NO:
Exemption, you should become subject to"the 'Workers' _
—Compensation--provisions=of-the-Labor=Code;you-must-forth-= -�---=---====A ,,LI,CATION:F__OR__ __.---_, --. _.--_.--- EXIT_HARDWARE:- -
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
___OCCUPANCY INSPECTION - -
_ Panic Devices
--LICENSED=CONTRAC-TORS-DECL-A-,RATION _ - -= --- - `-
El
I hereby affirm that 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 y`
effect. - ^ PARKING REq'D PROVIDED
SPACES
License Number Lie. Class Z
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 SIG ATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No. Date 1 c
0/1
HOME OWNER-BUILDER DECLARATION NO. OF EXIS v
G BUILDINGS
ON LOT AND USE
- - PI -
I hereby affirm that I am exempt from the Contractor's �� .✓/�
License Law for the following reason (Section 7031.5, Busi- ?, ?" i •" ';,
ness 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,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency J ,
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 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-me tioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
9-rd 9'L
Signature f Permittee. Date
11'6RI:I:RS'COfi1Pl{NSA"L[ON DECLARATION C
CE 875(11-841 MISCELLANEOUS APPLICATION
E 875
here.t.y affirm that l have a certificate ofconsent self 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._-. -- -__-Conipany- FOR APPLICANT TO FILL IN BUILDING
ADDRESS /
❑ C.ertlficd copy is hereby furnished.
XX �BUIL DI NG LOCALITY
ADDRESS pL S U &[3 f�/�
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. 3Lx ���r,, cwoss ST.
Date______—..__.__Applicant NEAREST DISTRICT NO. GROUP TYPE ,,�....���''' P ESSED BY
CROSS ST. O 5 Nr jT• le CONST
CFRIII ICATE OF EXEMPTION FROM WORKERS' a LEGAL (�
COMPFNSAIION INSURANCE' DESCRIPTION LOT NO. BLOCK MAP NIORWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT NOWNO. OF SLOGS.ON LOT USE ZONE SPECIAL CONDITIONS
by (he permit is for one hundred dollars (SI00) or less.) I uSE OF
SIZE OF LOT EXISTING BLDG. p
1 certify that in the performance of the work for which this D,
permit is issued, I shall not employ any person in any manneXx OWNER of building '
m as to become suhiccl to the Workers' Conipens:ltion Laws. 1 / OCCUPANCY GROUPEi:] c)
MAIL' Gj� //�
ADDRESS / �JL - - - —� V
Date--____-_--__-- Applicant- ----. - "I
TEL.
OCCUPANT LO
NOTICE FO APPLICANT: If, after making this Certificate of CITY NO.
�!!S-�.�oZ� CCUPAAD v,
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Conlpens:Ition provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USE I] GEOLOGY INSPECTION E] No Spec. Knowl.
deemed revoked.
OCCUPANCY INSPECTION ❑ Panic Devices
LICENSED CONTRAC DECLARATION _
I hereby affirm that I ;Illi 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 tinct Professions Code, and my license is in full force anix
effect. 1 Name of business PARKING
ter- SPACES REO'D 1EI
�=
PROVIDED
License Number ______.-_- Lic. Class C0 A
LIMITED TIME USE
Conlr:Ictor_ _ Date__ __ S """"� DATE DATE
FROM: TO:
El I ani 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 1�1/
SIGNATURE
inessand Professions Code). FINAL APPROVAL 9PRESENT USE OF BUILDING / /CP p
Lic.or Reg. No._____-____-_-.____ Date -
IiONIF OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
hereby affirm that 1 ani exempt from the Contractor's ;'];i;: ;•• ? `.?
License I.aw for the 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).
CONS IRUCI ION LENDING AGENCY PROPOSED USE OF BUILDING
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit
issued(Sec. 3097,Civ.C.).
Lender's Name--__.-----.-_-------
PROPOSED MAX.*OCC.
Lender's Address ___
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 ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter I TOTAL FEE 25-00
upon the above-Illeliticilled
+U` rty for inspection p rrposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Cf
— -- --- -
XX �7�
�ipnIl�In•I�f 1'rrnllll('r _ D:11e
WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (2-80) MISCELLANEOUS APPLICATION
I heriy .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:)
�olicy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. BUILDING ' �' LOCALITY
A DRESS _ -
Certified copy is filed with the county building inspection r NEAREST.
L CAL'ITY ,` C/� "
department: is - CROSS ST.
Date Applicant NEAREST DIST T'NO. G OUP TYPE ] PR SED BY.
CROSS ST: Y9 A
�'I C CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' 'LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT Nd.^ BLOCK MA•,. - HIGHWAY '
N0. (CIRCLE) STATE MAJOR SECO D LOCAL
(This,section need not be completed if the work involved NO. OF LOT, USE ZONE SPECIAL CONDITIONS 0
p TRACT,' NOW ON LOT,
by the permit is for one hundred .dollars ($100) or less.)
USE OF /n/
SIZE OF LOT •' EXISTING BLDG. cc
I certify that in the performance of the work for which this 0
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. AIL. `J J {� o/ ' OCCUPANCYGROUP
ADDRESS /T L/•/ �/V/' �a_ . (/ d
Date • Applicant ' Q &5
� to
.NOTICE TO APPLICANT: If, after making this Certificate of CITY ' �j T` 'rTvo� !V� G�t��/ OCCUPANT LOAD z
Exemption, you should become subject to the,•Workers' RDWARE:
— -
Compensation 'provisions of the Labor Code, you must forth-
"` AP.PLI'CA ION'FOR _ EXIT HA
with comply with such provisions or this permit shall be TRAILER USE Y GEOLOGY INSPECTION❑
deemed revoked. NO Spec..Knowl. ❑
- e - -
�' INSPECTION - - T -
Panic D vices
LICENSED CONTRACTORS DECLARATION ,
I hereby affirm that I am licensed under provisions of Chapter SAFE ry PERMIT L 1 (LIST ITEMS BELOW) rv0. 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 REQ'D PROVIDED
SPACES
License Number Lic.Class
LIMITED TIME USE
Contractor Date o ATE 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 7651, BUS- EXISTING BLDG. STORIES SIGNATURE
inessand Professions Code). RESENT USE OF BUILDING v, t.� FINAL APPROVAL
Lic.or Reg'.No. Date
HOME OWNER-BUILDER DECLARATION
NO.-OF EXISTING BUILD IMGs
ON LOT AND-USE
�45:29A
I hereby 'affirm that, I am exempt from the Contractor's
License Law for the following reason (Section 7031.5,•Busi- #•o o O O 8 8
'ness and Professions Code):. • NO.PARKING -
SPACES PROVIDED -
0 0 0 0 0 0 0 �
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). (/Jh" O�2 4`-8 6.
OPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY 9 , l �T t� 1vN
I hereby affirm that there is a construction lending agency... %Vi?0�-
for-the performance of the work for which this permit is
iss6ed,(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 rep esentatives of this County to.enter
up, the (love-mention operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee kf Date
i WORKERS'COIPEN'SATION DECL.'.`ial'ION 76M444 rr ` !" n� � l 'APPLICATION r�
r CE 875 11184) MIS CLLL/••k1 • L,
1 hereby affirm that I have a certifi Compensation
Insurance.
to self COUNTY OF LOS .ANGELES XILDING AND SAFETY DIVISION
insure. or a certificate of Workers*Compensation(nsurmce.or
a certified copy thereof(Sec. 3800.Lab.C.).
Policy No. -Company ADRESS FOR APPLICANT TO FILL IN 3
P
Certified copy is hereby furnished. BUILDG I
DDRESS Lt
F-1CertifiedIN ,GVY\� p/J\,� ICALITY '
Certified copy is filed with the countv building inspection LOCALITY NEAREST
department. Temple City C'ROSS ST.
Date Applicant NEAREST pISTRICT NO. GR P TYPE CESSED BY
• CROSS ST. k.J `� 7 CONST.
CERTIFICATE OF EXEMPTION FRO>1 aOR?-LRS LEGAL
i
COMPENSATION INSURANCE DESCRIPTION LOT NO. :BLOCK (MAP IG tIw Av
rip. (CIRCL_) STATE `MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed If the work involved TRACT `IOW ON LOT USE ?ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars 61001 or less.) USE
OF
I I SIZE OF LOT I EXISTING BLDG.
I :certify that in the performance of the .yoTk :cr •.yhich 'his -
permit is issued, I shall not employ an}' aerson in am' manner OWNER II(a, -A
Permit
so as to become suhiect to the \horkers Compensation Laws. �� OCCUPANC`' GROUP
Al
ADDRESS px
I Date Applicant 1 ll -
NOTICE TO APPLICANT: If. a--er making :!tis C�rt:ficare of x]c,TY� �� N01 �(�}'S CCCUPA.NT LOAD
Exemption, you <hould become subiect -.o the �Fnrkers
Compensation provisions of die Labor ti:,1de, you mus[ fort?r
APPL!CAT!CN `':)F cX HAF.C!NAR -
with comply with ;uch provis;oms or :his permit shall be I �� G -
-RAILER :JSE IJ GEOLOGY :NSP=-=ON No Spec. <:-io,, 1. L�
? deemed re%eked. -
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION:RX F8r1iC Devices
II hereby affirm -hat I am licensed under previsions of Chapter r
9 (commencing with Section 7000) of Division c of the Busi- SAFETY PERMIT (LIST ITEMS BE LO:'Ji NO. OF EXITS
ness and Professions Code. and my license is u1 fuil force and
effect. PARKINGREDO
�I I
SPGCES PR O`J ID ED
License Number Lic. Class G
LIMITED TIME USE
N C'ontract(1T_ Da t — TATE pA'E
N
W
Z ❑ P•JM: �O:
I am exempt from the ':icensing requirements as I am .t ,
M I licensed architect or a registered prnfessional engineer SIZE of No. CF INs ATT;/11
To s
r` ,-. 'll� EXISTING BLDG. �TOR1=5 G AT RE
Z acting in ;m professional _a..a: n' on 1. Bus-
° iness and Pr ofessicns Code I.
FINAL ? .OVAL
U PRESENT USE OF BUILDING x11
Lic.or Reg. No.
HOME OWNER-BUILDER DECLARATION' NO. OF EXISTING BUILDINGS �y
ON LOT AND USE ? tiL1:J•=x
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section7t)31.5. Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED
El 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
i 7044.Business and Professions Code).
X
CONSTRUCTION LENDING AGENCY
PROPOSED USE OF BUILDING C\o
I hereby affirm that there is a.constructicn lending a--encv _
I for the performance of the �%ork for which this permit is
issued ISec. 3097,Civ. C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's address
1 certify that l have read this application and state that the PERMIT FEE 25.00
above information is correct. I agree to comply with all County ISSUANCE FEE
r ordinances and State lawsrelating to building construction.
and herebv authorize representatives of this County to enter TOTAL FEE 25.00
upon the above-mentioned proeerty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
r i
wnature of Permittee Date
i
WQRKERS'COMPENSATION DECLARATION
CE 875 (11 84) M ISCELLANEOUS'APPLICATION
CE 875
hereby affirm that 1 have a certificate of consent self
insure, 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 ADDRESS
Certified copy is hereby furnished. BUILDING
XX ADDRESS LOCALITY
F Certified copy is filed with the count building inspection �
y. gip LOCALITY NEAREST
department. XX / CROSS ST.
Date Applicant NEAREST OISTRIS„Y;�ON`O GROUP TYPE PR CESSED BY
CROSS ST. / CONsr
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALC
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NOOF 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 dollars ($100) or less.) USE OF
1 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 manneXX OWNER of buil din C `'
so as to/'y`ecome subject to the W rkers' Comp nsation Laws. �f OCCUPANCY GROUP rr
MAIL
'^ I ADDRESS U
CX)_ DateNApplicant uJ
NOTICE TO APPLICANT: If, a er making this Certificate of cit �� _�, NOL 'y
Sd5 Lam/ OCCUPANT LOAD C,
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPL ATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑
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 a
effect. X Name of business PARKING
SPACES REp'D D PROVIDED
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
.1 ROM: TO:
El 1 am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATU
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg. No. Date �{ F
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS //Nql.0 / •� 0�
ON LOT AND USE ����L" �T i✓
1 hereby affirm that I am exempt from the Contractor's C
License Law for the 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
1 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. _ '•l
Lender's Address
PERMIT FEE `[
I certify that I have read this application and state that the 25 . 00
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 a ove-mentioned property for inspection purp ses.
XX XX S9EE REVERSE FOR EXPLANATORY LANGUAGE
S enature of ennittee Date Z
1
WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 875
I hereby a cert that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insurec
, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.). . 'fl
BUILDING
Policy No. Company FOR APPLICANT TO FILL IN
ADDRESS
Certified copy is hereby furnished. ILDING LOCALITY
ADDRESS w
Dr
Certified copy is filed with the county building inspection LOCALITY // , NEAREST
department. (/j CROSS ST.
Date - Applicant NEAREST DISTRI T NF' 6 OUP TYPE P CESSED BY
CROSS ST. _ �Jj J/ IY-� CONST.
'CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (✓a �f/�-)
COMPENSATION INSURANCE DEscRlarloN 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
SIZE OF LOT EXISTING BLDG.
I certify that in the performance.of the work for which this
permit is issued, I shall not employ any person in any manner OWN-or
` y
so as to become subject to the Workers' Compensation Laws. MAIL ADDRESS r, OCCUPANCY GROUP -� o
Date Applicant I„
TEL
NOTICE TO APPLICANT`. If,after making this Certificate of CITY -PrVH No. — OCCUPANT LOAD C/3 .
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 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. 0� I PARKING REQ�D pROV1D E
SPACES D
License Number Lie. 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 SIGN URE
iness and Professions Code). FINAL APPROVAL / _ 7
PRESENT USE OF BUILDING G'
Lie.or Reg.No. Date
NO FE
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 J.-;; fi:-•;
ness and Professions Code): NO. PARKING
El I, as owner of the property, will do the work and the SPACES PROVIDED
i{iW+= i 1 rE) 1 =i
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. _
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the ,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
upon the above-me 'oned propertypfor inspection purposes.
0 C -Z SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatuk of Permittee Date
1
WORKERS'COMPENSATION DECLARATION
CE 875(11-84) M I SC E SLA N EO U S APPLICATION
CE 875
I hereby affirm,that I have a certificate of consent nc self COUNTY OF LOS ANGELEcr BUILDING AND SAFETY DIVISION
insure, or a certificata,of,Workers'Compensation Insurance,or � v' •
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING t0
- ADDRESS
FlCertified copy is hereby furnished. BUILDING LOCALITY
D DR ESS
F1 Certified copy is filed with the county building inspection LOCAL NEAREST
department. CROSS ST.
Date - Applicant NEAREST DISTRICT NO GROUP TYPE �/ P SSED BY
CROSS ST.' (�L/y/� ,�� CONST. i//
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION.INSURANCE DESCRIPTION LOT NO. BLOCK 41461� 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
I certify that in the performance of the work for which this SIZE OF LOT O EXISTING BLDG.` �
permit is issued,.I shall not employ any person'in any manner O W N ER O•� - w �/i • 0 !:;
so as to become subject to the Workers' Compensation Laws. MAIL // OCCUPANCY GROUP
ADDRESS '6�, /, / �� f
Date• Applicant _ zz
w
NOTICE TO APPLICANT: If, after making this Certificate of ,CITY f� TN.L j� j» j��J OCCUPANT LOAD N
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- AP L CATION FOR EXIT HARDWARE:
..with--comply--With..such provisions Or this permit. shall be TRAILER USE GEOLOGY INSPECTION ❑
deemed revoked. - - - _ - ❑ No Spec. Knowl.
Y - - - - - Panic-Devices - -
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONx
Ej
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 N Q m O�
effect. Busi ness '• PARKING REO'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 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 516 ATURE
�—.
iness and Professions Code). FI-NAL APPROVAL
Lic.or Reg.No. Date 2-93PRESENT USE OF BUILDING (�
/
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS p _ - FEE__
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
usi ness and Professions Code): NO. PAR NG
0 I, as owner of the property, will do the work and the SPACES PROVIDED I , •± ! �I I7
structure is not intended or offered for sale (Section77
7044,Business and Professions Code). Z"
CONSTRUCTION LENbING AGENCY PROPOSED USE OF BUI DING
I Hereby affirm that there is a construction lending agency iz
{
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 a State laws relat'ng to building construction,
and her uthorize re a Ives of this C to enter _ TOTAL FEE a5 �Ip
up a ve do pop ty fI or i tion urpo s.
SEE REVERSE FOR EXPLANATORY LANGUAGE
i a u Date
y4R12KERS'COMPENSATION DECLARATION
CE 875(11-84) MISCELLANEOUS APPLICATION
CE 875
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 1`!n. CompanyFOR APPLICANT TO FI LL IN BUILDING
ADDRESS
Certified copy is hereby furnished. AD ORess 414 IhJ INIY9.� AA �' LOCALITY
0 Certified copy is filed with the county building inspection LOCALITY NEAREST 671
department. azeuAau 9CROSSST.
Date Applicant AREST 'w• �J�/y /� L DISTRICT NO. G OUP PE TYED BY
CROSS ST. �AV /(�// Q�/� �/L �/ CONST. P CES5
CERTIFICATE OFEXEMPTIONFROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO.. BLOCK MAP HIGHWAY
No. -(CIRCLE) STATE MAJOR R SECOND LOCAL
- NOOF BLDGS. '
(This section need not be completed if the work Involved TRACT NO.W 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 SIZE of 4T EXISTING BLDG. O
permit is issued, I shall not employ any person in any manner W VoCf PR910 ,Sk
so as to become subject.to the Workers' Compensation Laws. MAIL /� OCCUPANCY GROUP
DDR 94'I'4•� LAS ?lAN/}S d/p
Date Applicant L�LI
NOTICE TO APPLICANT: If, after making this Certificate of "CITY�i /�L/C e4To. 29S=G�2 1 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 sllall-be TRAILER USE ❑ GEOLOGY INSPECTION No Spec. Knowl.
deemed revoked: - - -- -, -- --
• - Panic Devices -
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ -
ET
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
ce
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
inessand Professions Code). FINAL APPROVAL S 3 7
J-FfRESENT USE OF BUILDING
Lic.or Reg.No. Date � rr
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
usi ness and Professions Code): NO. PARKING '= %-
❑ SPACES PROVIDED 7' ".1N -
I, as owner of the property, will do the work and the t y
structure is not intended or offered for,sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY ROPosED usE of BUILDING
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is r v
issued(Sec. 3097,Civ.C.).
Lender's Name V
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-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature 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.)
Polic No. Com any BUILDING
Y P FOR APPLICANT TO FILL IN ADDRESS. v
Certified copy is hereby furnished. 006UILDING ' � LOCALITY
ADDRESS
El
Certified copy is filed with the county building inspection NEAREST
department. CROSS CROSS ST.
Date Applicant - EAREST 'DISTRICT T��PE PROC /SED BY
CROSS ST: ' NST.
CERTIFICATE OF,EXEMPTION FROM WORKERS' iecaL` L
COM PEN SAT ION"INSURANCE DESCRIPTION LOT NO. BLOCK MAP/�///( MIGMWAV _}
-.. .-/-J(/�?/ (CIRCLE) - STATE M A J OR,S ECO D LOCAL a
/' NO. OF BLDGS.
(This section need not be completed if'the WOLIc InVOIVed . TRACT NOW ON LOT USE ZONE 'SPECIAL CONDITIONS O
by the permit is for one hundred'dollars'.($100) or less.) U
USE O N
+, SIZE OF LOT EXISTING-BLDG-. /v Ir
I certify that in the performance of the work for which this 0
(permit is issued, I shall.not employ any person-in"any manner OWNER
o as to become subject to the.Workers' Compensation Laws. MAIL ^f �^ �/� OCCUPANCY_GROUP _ EKE-
W
.7I. - ADDRESS'- i fJ CSO S '`��.YY� G.
Date Applicant (n
'NOTICE TO APPLICANT: If, after making this Certificate of\,) )� 1`/1QFy��� rvo� 8.1�' a -tJja; OCCUPANT LOAD z
Exemption, you should become' subject to the Workers' -
'ompensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE GEO GY INSPECTION O
deemed revoked �No Spec. Knowl. O
LICENSED CON TRACTORS'DECLARATION OCCUPANCY iNSPECTIO anlc.'DeviceS
I hereby affirm that I am licensed under provisions of ChapterSAFETY PERMIT Q (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 PARKING.
effect. SPACES REq'D O PROVIDED
SE -CoLicense Number Lic.Class
'LIMITED TIME USE. -
Contractor
ntractor 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 IlvsPecroR's
acting in my professional capacity (Section:7051, Bus-, XISTING BLDG. - STORIES SIGNATURE
iness and Professions Code). I FINAL APPROVAL
- PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION. No. O EXISTING BUILDINGS
ON LOT AND USE G O � O.9 (t .•
I hereby, affirm that, I am exempt from the Contractor's L O Q 1 It
License Law for the following reason (Section 7031.5, Busi- #:0 0 0 0 88 '
ness and Professions Code): NO. PARKING
SPACES PROVIDED - 0:0.0 0 0 0 0
I, as'owner of'the'property, will do 'the work and the -
structure is not intended or offered for sale (SectionQ 2(� 8 7
7044, Business and Professions Code).
PROPOSED USE oF,BuiLDIrvG Att _
CONSTRUCTION LENDING AGENCY /
I hereby affirm that there is a construction lending agency N
for the performance of the work for wJhich.this permit is
issued (Sec. 3097,Civ.C.).
tender's-Name
♦ `
PROPOSED MAX. OCC.
Lender's Address PERMIT FEEb.
I certify that 1,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
u Athebove-mentioned rty for inspection purposes. SEE REVERSE FOR EXPL'ANA-TORY'LANGUAGE o ermittee
WORKERS'COMPENSATION DECLARATION MISCELLANEOUS APPLICATION
�1
CE 875( r I
I h(ilCE 875 11-84)eby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION , ,lull
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
FiCertified copy y is hereby furnished.
ADDRESS LOCALITY Law
�•
DCertified copy!is filed with the county building inspection LOCALITY T NEAREST
department. - - , / • C � CROSS ST.
Date Applicant NEAREST A V_ DISTRICT�J�O. GR P TYPE / PROC D Y
CROSS ST. ,i;L/I] CONST. V
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V (�Q
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
- NO. (CIRCLE) STATE MAJOR SE CON 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
SIZE OF LOT EXISTING BLDG. d
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 y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ® o
ADDRESS
Date Applicant u,
NOTICE TO APPLICANT: If, after making this Certificate of CITY ' � TEL.
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 OI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Know].
deetned revoked.
_ _
LICENSED CONTRACTORS DECLARATION occuawrlcY 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 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 INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES .I NATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING �J
Lie.or Reg.No. Date
6/
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING UILDINGS Q -- - /440
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). 2 5 2 7.0 A
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
# 0'00088
I hereby affirm that there is a construction lending agency �syG^ 3,��G �¢ t� CI—e
for the performance of the work for which this permit is .�� o 0 0 o m:o o z
issued(Sec. 3097,Civ.Q.
Lender's Name Q $ $=86
PROPOSED MAX. OCC.
Lender's Address
,
I certify that I have read this application and state that the PERMIT FEE
above information is co . agree to mply with all County ISSUANCE FEE
ordinances and St,W laws re o building construction,
and hereby aut rite sentatives of this County to enter TOTAL FEE
upon the abov ' ion propert for inspection purposes.
- — -6sEE REVERSE FOR EXPLANATORY LANGUAGE
ture of PVmittee Date
WORKERS'COMPENSATION•DECLARATION 76M444
CE 875 (2-80) M-ISC.ELLANEOIJS APPLICATION
L hereby.affirmthat I .have a certificate of consent to selfCOUNTY 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 ADDRDESS
Certified copy is hereby furnished. ILDINGd r' .I LOCn,uTv I
F71 _ A DRESS l Z L/TS,.: IU/Y �J//� '.
Certified copy is filed with the county buildinginspection
. NEAREST
department. o'c ALlry / E LE t+!? C / �J CROSS ST., nafj��
Date Applicant NEAREST DISTRICT TGROUP TYPE - PRO E USED B
CROSS ST. S'G I t� CONST.;/
CERT.IFICATE'OF EXEMPTION FROM WORKERS' "LEGAL
DESCRIPTION LOT NO. ^ BLOCK MAPHIGHWAY
COMPENSATION INSURANCE S n7 STATE MAJOR SECOND`LOCA. tl,
- NO. (CIRCLE)
(This section, not be completed if the woik involved NO::of e1.Das. p .
p TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit:is for. one,hundred dollar's ($100) pi iess.)' USE1= V
SIZE OF LOT- � EXISTING BLDG.
I certify that in the performance of the work for which this /�7 / q� O
permit is issued, I shall not employ any person in any manner WNER WlLL�RM U` /r�CCRSE' MES MA ��E 9 (~j
so as to become subject to the Workers' Compensation Laws. AIL O� OCCUPANCY GROUP LU
L) ,
DRESS '.
Date Applicant N
NOTICE TO APPLICANT: If, after,malting.this Certificate of CITY EM L'F _ �jrvoTE
� OCCUPANT LOAD Z
Exemption, -you',should ,become--subject- to he Workers'
Compensation provisions of the Labor Code, you must forth-
N6.
KATION FOR EXIT HARDWARE:•
with comply.-with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION'❑ - El
deemed revoked E NO.Spec. Knowl.
_ Pa •c''Devic .
LICENSED.CONTRACTORS DECLARATION occuaAiucv wsPECTIory
I hereby affirm that I am licensed,under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) a
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 REO'DF.� PROVIDED
License Number 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 N0.'0F. IIv SIGNATURE R's
I in my professional capacity (Section 7051, Bus_ EXISTING BLDG. STORIES SIGNATURE
mess and PrOfesslons Code). . - ESENT USE OF BUILDING - FINAL APPROVAL
Lic:or.Reg.No. Date
Li Ll — - -
HOME OWNER-BUILDER DECLARATION No:OF'EXISTIN�'-G' dS — — -
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 z,5,3 4,3J A
.. )''' - SPACES PROVIDED
I, as owner of the,property; will do the work and the ;# o:o'o o 4'0
structure is. not intended or offered for sale (Section '
7044, Business and Professions Code). o'o^e o 0 0 0
/ 'ROPOSED�USE OF BUILDING..
CONSTRUCTION LENDING AGENCY - 0 5 2.0-S'�.
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 vRoeoseo 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 Issuwnlee FEE
ordinances and State laws relating to building construction,` TOTAL FEE
k
d hereby' authorize representatives of this County to enter
on the' bovementione perty' for ins ection �o es. SEE-REVERSE R EXPLANATORY LANGUAGE
[/l/
Si to e o tte Date
WORKERS'c6MPENSATION DECLARATION. 76M444 p� c- APPLICATION
/� /� T N
CE 875 (2-80). M.1�:L,I, �- S /1'� "�A 1 I'o 1�!
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.copy thereof(Sec:•3800;:Lab,..-C.)
ksPolicy No. 'Company ""FOR-APPLICANT•TO FILL IN w�oeEss
Certified copy is hereby'"furnish ed: BUILDING' LOCALITY
Q,1 4 � w,.' T p�tp/� '�
❑ ADDRESS ,11 '1.- L.Y�/� � • .I-Ci'G� \f I
0 :Certified copy,Is filed with the county building inspection _ NEAREST
department. G 'Local rr CROSS ST.
/T L
Date Applicant '�- NEAREST - DISTRICT�V O:. Gg10UP_: TYPE PRO E ED B�'
-, -CR OSS'ST: U\ //(✓71 C;ONST�
_. .V V_1� S�t�..-
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
—.,- •i— - •- _ - ;D ESCRIPTI,ON LOT_.;'NO .BLOCK ,M Ac MIGRw Av -
COMPENSP TION INSUR'A'NCE' '
a `'' ,".STATE'MAJOR SEC ND LOCAL
.. : NO'OF BLDG rvo (c CIRCLE
This'section,need not'be'completed
if, the work involved S
(• - p ._ TRACT ,• - NOW ON.LOT -
"o- USE ZONE SPECIAL CONDITIONS
by-the' pe mit-is foi'one,,hundred;d'ollii s (�100).or-less.)`' USE of
SIZE.OF LOT , EXISTING BLDG - '
-' ,
- -.:, V - .
I'cerfify''that in the 'performance of the work.for`_which this "
- OW-NER
-
permit is issued Lshall not employ any person-m any manner Y
m
O
so as to become subject to!the-Workers'"CompensaUonLaws; Q /� ' - w- OCCUPANC GROUP {n(— a
MAIL' \-T -�/✓ -
..
ADDRESS TNN�Agi'- ,. 1 .• ,
Date Applicant'
NOTICE TO APPLICANT If, after snaking this Certificate of e-CITY OCCUPANT LOAD '
''tn
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 of this permit shall be TRAILER USE GEOLOGY Spec INSPECTION'❑, -
..deemed-,..deemed-,revokeddeemedevoked hlo KrlOw
—_ - e
OCCUPANCY INSPECTION}}qq�� C., " Panic"D`evics ❑ ___ ' l
LICENSED.CONTRACTORS DECLAR'A'TION h
I hereby,affirm that,I am licensed under provisions,df-Chapter. swFETv PERMIT 1 (LIST ITEMS BELOW)
9 (com'mencing.with Section 7000) of Division.3 of the Busi =
ness and Professions.Code; and my license is.in full;foree and PwRKING. N
O. OF EXITS -
effect. - - - :-R ECI'D'•� ":PROVIDED
- - SPACES': LL��..JJ
License Number' Lic..Class "
LIMITED TIME USE,
Contractor - Date
.GATE GATE
OY .,. FROM: TO:
I am exempt from the licensing, requirements.as I am a
licensed architect or a registered professional engineer' SIZE of No; of # •'d NgP� ��z s
acting in tmy professional capacity (Section 7051; Bus- EXISTING BLDG STORIES SIG wriYeE .
me.sand P' fessi6ns'CO. ).'.. - �.pRESENT USE.OF'BUILDING v
v..� Y`/"
FLN'AL APPRO AL ® 8 8
Lic.or Reg.No. Date
NO.'.OF EXISTING"BUILDINGS•.s - 021 8-'rLIlJ R
HOME OWNER,-BUILDER DECLARATION ON LOT,AND'USE
Ihereby'aff".Yhaf I am-exempt' from the;.Contractor's
License Law for the following reason.(Section 7031.5,;Buss
nes§and,Professions`Code): No:PwRKirlc
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).:,
' ,F.sROPOSEDU SE OF BUILDING , -
CONSTRUCTION LENDING'AGENCY
L 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.) PC
a V. _ l ,
' Lender's Name V �'
..PROPOSED M AX. OCC-
14
-Lerldei'S Addre SSLA+ _ PERMIT-FEE. - -
Icertify that I.have"read„this application and state that the
above information is-correct.I•agree to comply with all County IssuwNCE FEE
ordinances and State laws,.relating,,to building construction,
and hereby.authorize'representatives,of this.County'to enter;' TOTAL-.FEE
upon'the'above rationed property for inspection purposes: SEE REVERSE'FOR EXPLANATORY-LANGUAGE
Signature of Permit a Dat '