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Home My Public Portal About9443 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION E 875(11-84)4 C :M I SC E L LA N E O U S APPLICATION CE 87 I hereby affirm that I have a certificate of consent 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. BUILDADDRSS ING (F / Lo caurY E 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED By CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION 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 I certify that in the performance of the work for which thisOSIZEOF EXISTING BLDG, opermit is issued, I shall not employ any person in any manner EI A(� 1so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP a( ~Date Applicant A Y uu�J NOTICE TO APPLICANT: If, after making this Certificate of +4 NO _ OCCUPANT LOAD Exemption, you should become subject to the Workers' APP CATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic 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 SPACES REO D D D PROVIDE J .r License Number Lic. Class LIMITED TIME USE Contractor Date 4 DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineerSIZE 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 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 ❑ 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). CONSTRUCTION LENDING AGENCY PROPOSED USEOFBUILDING 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. x'``"' Lender's Name int _ PROPOSED MAX. OCC. �''"• ~' tlf11 Lender's Address h'w! N,t. PERMIT FEE ^' ` I certify that I have read this application and state that the ' 1 above information is correct.I agree to comply with all County ISSUANCE FEE 1 "` III ordinances and State laws relating to building construction, and heyejoy authorize representatives of this County to enter TOTAL FEE upon t above-mentioned property for inspection purposes. ' � SEE REVERSE FOR EXPLANATORY LANGUAGE � •`-� '`•� [I,1 ignat re of Permittee Date t) •Xl I.�/ .4:J WORKERS'COMPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION ' *.,: CE 875 (11-84) L, ) I hereby affirm cet fi at I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �IL�II 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 pDDREss Certified copy is hereby furnished. BUILDING ADDRESS LOCALITY Certified copy is filed with the county building inspection LOCALITY /� [� NEAREST (� department. CROSS ST. � Date ApplicantNEAREST DISTRICT NO, G T PE ' / PRO 5�D BY CROSS ST. ONST A/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL "r COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP. HIGHWAY NO. (CIRCLE) STATE MAJOR SEC#D LOCAL NO. OF BLD GS. (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 EXISTING BLDG. II o permit is issued, I shall not employ any person in any manner OWNER ��0�►'�U C. so as to become subject to the Workers' Compensation Laws. MAIL 11'7[r. w"r r �,LCr? {Bl S Ib OCCUPANCY GROUP o DDR ESS' Date Applicant LUJ NOTICE TO APPLICANT: If, after making this Certificate of CITY No s0 OCCUPANT LOAD Exemption, you should become subject to the Workers' gppLl ATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. El deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION El 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 D PROVIDED SPACES License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE DI am exempt from the licensing requirements as I arri a licensed architect or a registered professional engineer SIZE OF NO. OF FROM: To: INSPECTORS acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). /{ Lie.or Reg.No. Date RESENT USE OF BUILDING FINAL APPROVAL 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 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section ACU.s 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCYPROPOSED USE OF BUILDING �j`zZ�t. �Q��e CO FEE I hereby affirm that.there is a construction lending agency %V—(2— for the performance of the work for which this permit is I_000-0001 1/27/8 issued(Sec. 3097,Civ.C.). Lender's Name Et .moi I Prl 4.461 Lender's Address PROPOSED MAX. OCC. S, PERMIT FEE O 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 11�3_ CIG upon the ab -mentio ed property f inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Pen ee Date WQ:ZKERS'COMPENSATION DECLARATION 75 (11-84) CE 875 M ISCELLANEOUS APPLICATION " ' < - CE 8 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, o;� a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. BUILDING Company FOR APPLICANT TO FI LL INT CY,i ADDRESS Certified copy is hereby furnished. BUILDING ADDRESS �•. LOCALITY �v 0 Certified copy is filed with the county building inspection LOCALITY /i NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPECESSED BY CROSS ST. n G I CONST.0 VO CERTIFICATE OF EXEMPTION FROM WORKERs'. LEGAL / 4a COMPENSATION INSURANCE DESCRIPTION LOT NO. L >l BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDG S' W (This section need not be completed-if the work Involved TRACT NOON LOT usZ/V SPECIAL CONDITIONS, by the permit is for one hundred dollars ($100) or less.) 7-JUS of SIZE OF LOT a / 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 OWNER &WftC aT/ C-> so as to become subject'to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP �- o Date Applicant ADDRE fG� t33 L JI TEL 7 OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of cITY No. ( l i >3 �d v, 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 herebyaffirm 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 2�n1� '� PARKING effect. SPACES REq'D D PROVIDED O License Number Lie. Class LIMITED TIME USE Contractor- Date DATE DATE . ❑ I am exempt from the licensing requirements as I am a - PROM. TO. licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES sl URE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL 0- 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 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). 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(Sea 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 b -mentionp operty.for inspection purposes. t SEE REVERSE FOR EXPLANATORY LANGUAGE v r � Signature of P mittee- Date 1V0R1:1`.RS'CONIPI{NSA"PION DECLARATION CE 875 (11-84y MISCELLANEOUS APPLICATION - CE 875 hereby affirm that 1 have a certificate of consent tself i COUNTY OF LOS ANGELES BJILDING AND SAFETY DIVISION nsure, 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 BUILDING — ADGRESS ❑ Certified led L'O))y IS hereby furnished. BUILDING /] 2 t/ �. .y Pig- Certified I - LOCALITY XX ADDRESS l 7 /V l� Certified copy is filed with the county building inspection.. �ocITY r' NEAREST department. 3Lk ALCROSS ST, Dale...... Apphca nt.__--_.--__ NEAREST DISTRICT NO. IZOUP TYPEP ESSED BY CROSS ST. /�`� /� CONST.('hR"III 1('A'hE OP EXEMPTION FROMWORKERS' LEGAL COMPENSATION INSURANCE DESCR I PT I ON LOT NO. BLOCK MAP HIGHWAY NO. F BLDGS. n0. (CIRCLE) STATE MAJOR SECOND LOCAL (fills 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.) USEOF SIZE OF LOT EXISTING BLDG. 1v O 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manneRX OWNER of buildingGI f� Tib r` So as to hcconu' subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP C.) ADDRESS ® U Date------___-- Applicant.-- --- — L 1 TEL' OCCUPANT LOAD NOTICE TU APPLICANT: If, after making this Certificate of CITU No. v_) Exemption, you should become subject to the WorkersAPPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. ❑ LI(_ENSEDCON"TRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby" affirm that I all) 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 Cfeffect. nix ' REO'D '11� �_ 1 Name Of business PARKING ('�) PROVIDED E:=� ��'U SPACES J License Nun)bcr —_ Lic. Class LIMITED TIME USE Contractor- _..._.-_.___.__-_. ___._ Date_____ DATE DATE 1 ani 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 inessand Professions Code)' I FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg. Date HOME OWNER-BUILDER DECLARATION NO. of EXISTING BUILDINGS ON LOT AND USE I hereby aff inn that I and exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Colley: NO, PARKING I, as owner of (lie property, will do the work and the svacEs PROVIDED structure is not intended or offered for sale (Section j 7044,Business and Professions Code). CONS IRUCIION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm) that there is a construction lending agency fir the performance of the work for which this permit is issued(Sec. 3097,('iv.U.). Lender's PROPOSED MAX'OCC. •� '�' m Lender's Address--- "-- - - ---- ------- _ PERMIT FEE I certifv 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 a Slate laws relating to building construction, Wid here tlrorve representatives of this County to enter TOTAL FEE 25-00 uponN>7uve-menti )e4l property for inspection purposes. s_: ., SEE REVERSE FOR EXPLANATORY LANGUAGE XX XX � .- i uORJ:E2S'CO`,Ii�ENSATION DELL.\RATION' 76ivt444 M ISCELLANEOUS APPLICATION CE 975 11 1 841 1 hereby affirm that J have a certificate of consent to self COUNTY OF LOS ANGELES., BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Copensation Insurance,or �+ia certified copy,thereof(Sec. 3800;Lab.C.). - 1 Policy No. Company FOR APPLICANT TO FILL IN BDDRE SS " ADDR ss / 77` Z- o Certified „opy•is hereby furnished. BUILDING ADDRESS LOCALITY I 0 Certified copy is tiledi'th.the county building inspection .X Loc"ALITY NEAR Est 'department. 'kLl CROSS ST. . Date .-\ppllcant NEARESTOISTI! NO, GRO TYPE GESSED BY CROSS.ST. 6j / �(/ CONST. t CERTIFICATE OF EXE}IPTIOV FROM WORKERS LEGAL a COMPENSATION INSURANCE 0ES CR I P T 10N LOT NO. BLOCK n wlGwW gr'" SLOGS. - NOP (CIRCLE) - -TATE MAJOR SECOND LOCAL (Tills section need not Ile completed If the Work involved TRACT '.NOW ON LOT USE ZONE SPE'.CIAL CONDITIONS by the permit is for one hundred dollars ISM) lir less.) USE OSTINFG BLO.G. � ' J 1 certify that in 'he Decf '�" urmanee of :he cork fe: hich alis SIZE OF LOT E:CI permit is issued, i shall nor employ any person in any manner X OWNER 01 iA so as to become �uhjecr -o the ''\orkers• Comvensation Laws. OC1IJP4NCY GROUP . V MAIL I {1D OR ESS Date�____ .\crlicanr TEL. NOTICE TO APPLIC-\NT: If, uter makLm: :his Cen'uicate of aITY s No. �/ 1�� 1pZ� OCCUPaNT LOAD Exemption, you iitould become subject -o rhe Workers' T-e41L CA Comvensation provisions of the Labor Code. }rou,must for-Th- APP CATION FOR EXIT HARCWARE with comely ''kith <u:h orovi.sions I-r .nis -�e:mit ;trail be — (— Ie'.' "RAILER 'JSE ,1 GEOLOGY INSPEC7:ON _ - I�JO Spec. Know). L �j hied revoked. y LICENSED C ONTR.aCI'ORS 0ECL.\R.\110.� occJPANc'r INSPECTION B" Panic Devices 1 hereby af`irm that t am licensed under provisiensof Chanter SAFETY PERMIT (LIST ITEMS 3ELOW) a 9 Icommencine with Section 7000) of Division 3 of ate Busi- NO. OF EXITS ness and Professions Code. Ind my license is in 'hll .'orce Ind effect. - PARKING REO.O PROVIDED �I A SPACES `— License Number _ Lic. Class LIMITED TIME USE LUn[racwr DIT.-- I ateI am iz: npr 'rrm hr 'icensm'_ :eouire vents :, 1 Jia a y - 1I - INSPE CTO RS"I � he -tied ar cater: or i -e^ts[ered �rnression:l e;[ctn_•e: ;IZE OF � No. OF ? aL„n_ in '.il Dr Ute,sional )_1. 3«C- =X=:NG 3LOG. iTCR1E5 51-?AT-RE iness and P-ofessions Code). -- _ --- FINAL APPROVAL 3 �4 ESE'IT 'JSE OF 3UILDING {/q_-D8 U _ I Lic.car Rce. No. HOME OWNER-RLILDER DECL.0.\f10`: Na. of EXISTING BUILDINGS N LOT AND USE 1 hereby affirm than t .tn exempt i-nm ate Contractor's License La\% for the tcllu'.r"ine reason 1Se,:iun -031._. R«si ness and Protessions Codel: NO. PARKING PACES -ROVIDED ❑. 1, as owner of :he oroperrj•. %•till do the %ork ind :he struc ure is sot intended or otte::;d nor aie Section 044.R«;iness-and Professions Code). V A PROPOSED USE OF BUILDING CONSTRICTION I-ENDING I hereby affirm that ;Here is a construction lending agency for the performance of the work for which this permit is issued I Sec. 309.-.CiV.C.1. Lf+`� - PROPOSED MAX. OCC. I-glider's:\d«ress - ( PERMIT Fc: .. 25,.00 tom. I certifv that I have read this application and state ,hat the L above information is correct. I agree to comply ,yith all County j ISSUANCE FEE I ordinances and State lairs relatin_ to building construction, r q ("f :ted hereby authorize representatives of this Count} to enter TOTAL FEE 25.00 up the roomy for inspection purposes. L X '� ]�EE REVERSE FOR EXPLANATORY LANGUAGE Q ! J WORKERS'cQMPENSATIONDECL.aRAT10N CE 875 '11-841 MISCELLANEOUS APPLICATION CE 87.�i 1 herebv affirm that I have a certificate of consent to self1 insure..-Jr,a'eertificateot'Workers Compensation Insurance.or COUNTY OPLOS .ANGELES � ' BUILDING .AND SAFETY DIVISION . rl a certified copy thereof(Sec. 3800.Lab.C.). 7 _—) Policy No. —Company FOR APPLICANT TO FELL IN ADDRESSy a Certified copy is hereby furnished. ADDBUILDING p 2 LTJ r�i(/!�S �lv ADDRESS E.SS 6 I_ LOCALITY ! I 0Certified copy is filed with the county building inspection LOCALITY NEAREST department. Temple City CROSS ST. Date Applicant NEAREST r'` �/J�/�Z DISTRICT NO, GROILP TYPE OCESSED BY CROSS ST. O , CONST CERTIFICATE OF EXEMPTION FROM WORKERS- LEGAL � i COMPENSATION INSURANCE ' OESCRIPT'ON LOT NO. I !BLCCK NO. OF SLOGS, I (CIRCLE!MAI I+IG NW Av ..STATE MAJOR SECOND LOCAL I NO. (This section need not lie completed if the.,�vorkinvolved I TRACT NOW ON LOT USE ?ONE SPECIAL CONDITIONS by the permit is for one hundred dollars (5100) or less.) ? USE OF h I SIZE OF LOT I EXISTING BLDG. 1 certify that in the Performance of :he Mori: for •t'hich 'his 'p permit is issued. I shall noremploy any nerson ;n any manner OWNER �K �GCJ � Z % so as to become subject to the Workers' Compensation LakrS. /�/��/ p J�rJ� e �f 7 OCCUPANCY GROUP .n-w I L ./�r�� .�U GG1G�G�N — ADORESS J Date Applicant _ _ E . NOTICE TO APPLICANT: If, ,iter making :!his Ccrtiiicaie of $I cIT-- -§ rf /�Q ! Z vo�3lQ— q —dgOCCUP4N• LOAC Exemption, you ,hound become sliblect ro the WOrkerS Compensation provisions of the Labor ;ode, you must forth- APDLICATICIV COR °X IT HARIDWAFE: i with comniv with ;uch provisions or :his ,permit sltail be ,RAILER USE I GEOLOGY :NSPECTICN deemed evoked. — No Soec. <no�,vl. LICENSED D CON1 RACTORS DECL,kRATION OCCUPANCY INSPECTION U Panic Dev.Ires ❑ I hereby affirm that I am licensed under Provisions oi'Chacter ^ (LIST ITEMS BELOW) _ i 9 (commencing with Section 000) of Division 3 ') the Basi- SAFETY PERMIT NO. OF EXITS - ness and P-ofessions Code, and nn. license is in full force and effect. n PARKINGj ! / / SPACES REO.O I I PROVIDED T License Number Lic. Class LIMITED TIME USE N Co nRactor Date - : i:. L..e�-L.- f DATE oA-E N I am exempt froth the iicensing requirements as I am .I Tom' m I licensed architect or a registered professional engineer 31ZE OFIO, OF INSPECTOR'S z actin_ ;n my Professional :anaaiC'r Se:;ion _051. Bus- EXISTING BLDG. _TCRIEs a ;_--p^SdGNATUREIj . 9 Iness and ProfessiCnS Code L. - - F qfl n,J^I^F-1t...,L-.._ FINAL APPROVAL J PRESENT USE OF BUILDING _ Lic.or Rei. No. Date HOME OWN1:-R-!3 ILDER DEC-L.-\RATION NO. OF EXISTING BUILDINGS ON LOT AND USE - I hereby affirm that I am exempt from the Contractor's I License La%% for the followins 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 ;ale (Section ! 704.1.Business and Professions Code). _ A� /7� CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING �T��1 �/t/O�/N�D i hereby affirm that there is a construction lending agency l� I1,111f a p—U� 4-Z& for the performance of the .cork for N%hich this permitis 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 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 ' 1 upon the above-mentioned property or inspection purposes:.. SEE REVERSE POR EXPLANATORY LANGUAGE i - ' Sienature of Permittee Date h I