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HomeMy Public PortalAbout9451 1/2 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) I�'�/�{� �SC E L LA N EO U S APPLICATION PPLiCATI0N CE 875 I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or'a certificate of Workers'Compensation Insurance, e,07 a certified copy thereof(Sec. 3800,Lab.C.). Policy No. CUmpanyFOR APPLICANT TO FILL IN BUILDING J/ ADDRESS -.• ADDRESS 7 ❑`C'.ertified copy is hereby furnished. X BUILDING ADDRESS I 4qSl Z LAS T-W5 LOCALITY Certified copy is filed with the county building inspection LOCALITY •'�{- l^ p department. -r G 1/I Pt� C ) I 1 ( '1�(a NEAREST CROSS ST. Date Applicant NEAREST D/SC� DISTRICT NO. GROUP TYPE P ESSED BY CROSS ST. , O /i .�j CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL d �- 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 this SIZE OF LOT EXISTING BLDG. o permit is issued, I shall not employ any person in any manner OWNE --) so as to become subject to the Wo sCompen tion Laws. MAIL OCCUPANCY GROUP �� o Date 06 ADDRESS cW.s Applicant LLI TEL. OCCUPANT LOAD D_ NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. 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 ❑ 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 PROVIDED SPACES 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 OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL .1�7 �. A� PRESENT USE OF BUILDING ` (N•••�j Lic.or Reg.No. Date Re—FA/t. MARKET HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS �j�/ NO FEE 1 I hereby affirm that I am exempt from the Contractor's ON LOT AND USE License Law for the following reason (Section 7031.5, Busi { ti x ;,_:- Hess and Professions Code): NO.PARKING i li:( ij—1 ji�(E t� vi 1V: .•_ SPACES PROVIDED Fri •-y 7 I, as owner of the property, will do the work and the ri 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 �6 Tf}1L U,5 7!k ESS 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, -arid hereby authorize representatives of this County to enter TOTAL FEE upon the a-n ntioned property for inspection purposes. fi ©E /� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875 MISCELLANEOUS /® P P p I C g T I®N •• CE 875(1 i-84) � /''i L P'1 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANG`�LFFS BUILDING AND SAFETY DIVISION IL JI insure, ora certificate of Workers'Compensation Insurance,or r a certified copy thereof(Sec..3800,Lab.C.). xBUILDING' Policy No. Company FOR APPLICANT TO FILL IN pDDRE55 / ���, Certified copy is hereby furnished. BUILDING (J ADDRESS 7Z2 I-AS LOCALITY El Certified copy is filed with the co my building inspection LOCALITY NEAREST department. / 7 CROSS ST. Date Applicant - NEAREST DISTRICT NO. GROUP TYPE CESSED BY CROSS ST. ry CONST. o CERTIFICATE OF EXEMPTIO FROM WORKERS' LEGAL COMPENSATION IN URANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) S ATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be compl ted if the work involved TRACT NOW ON LOT USE ZONE SPECIAL.CONDITION by the permit is for one hand d dollars ($100) or less.) usE of SIZE OF LOT p EXISTING BLDG. / d I certify that in the performanc of the work for which this y permit is issued, I shall not empl y any person in any manner OWNER / ' , so as to become subject to the orkers' Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS o _ C) Date Applicant 8 TEL' OCCUPANT LOA Cl- NOTICE TO APPLICANT: If, after making this Certificate of CITY Q�/ No. p z Exemption, you should be ome subject to the Workers' ,O o APPLICATION FOR EXIT HARDWARE: _ Compensation provisions of e Labor Code, you must forth with comply with such pr visions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Howl, deemed revoked. LICENSED CONT ACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic De v ces I hereby affirm that I am censed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencing with Sect' n 7000) of Division 3 of the Busi- No. OF ITS ness and Professions Cod ,and my license is in full force and L A effect. PARKING RE D PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt fro the licensing requirements as I am a licensed architec or a registered professional engineer SIZE OF NO. OF PROM. TO: INSPECTOR'S acting in my pr fessional capacity (Section 7051, Bus- iness us EXISTING BLDG. STORIES _ S16 NATURE inessand Profes ons Code). FINAL APP12oVAL PRESENT USE OF BUILDIN Lic.or Reg.No. Date { � ti •fir. HOME OW ER-BUILDER DECLARATION No. OF EXISTING BUILDINGS //' Is: 1�' ON LOT AND USE 11 fl i l ', FIN yo 15 I hereby affirm t at I, am exempt from the Contractor's Vil Ali It.. ���`'I License Law for t e following reason (Section 7031.5, Busi (/I Hess and Professio SCOde): NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED l structure is not intended or offered for sale (Section 7044,Busin ss and Professions Code). , CON TRUCTION LENDING AGENCY PROPOSED USE OF BUILDING G ty r I Hereby aff• that there is a construction lending agency for the perfor ance of the work for which this permit is issued(Sec. 30 7,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Addr sem" I certify that I have read this application and state that the PERMIT FEE above informat•on is correct.I agree to comply with all County. ISSUANCE FEE ordinances an State laws relating to building construction, and hereby au ho i rr sentatives of this County o enter TOTAL FEE o the abov - on� property for inspecti n pur os es. SEE REVERSE FOR EXPLANATORY LANGUAGE 11?9— Sigttle of rmittee Da WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 f� I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ylull 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 BAUILDING /A DDRESS Certified copy is hereby furnished. BUILRDESSING �S/ LOCALITY ADD 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department. yr CJ CROSS ST. Date Applicant NEAREST DISTFF��T N �G O/UP ITYPE. P ESSED BY CROSS ST. FI� /4 UP CONST.'l/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �L✓✓OOo r COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY IVIA (CIRCLE) STATE MAJOR SECOND LOCAL NOOF LDGS. (This section need not be completed.if the work involved TRACT NOW. ONBLOT USE ZONESPECIAL 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 so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP -� Date Applicant ADDRESS 13400 �� 400 TEL• r/ OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY A n No�Z • 3 �Sq it y 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION E] No Spec. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION El Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI (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 PROVIDED SPACES 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 OF NO. OF IN GTOR acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES ddd SIG 6 NATURE iness and Professions Code). FINAL/APPROVAL PRESENT USE OF BUILDING /g ;J Lic.or Reg.No. Date hi -,� / �x HiI Ala C ,efi GVM HOME OWNER-BUILDER DECLARATION NO. OF EX4STING 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 aIM ;;F ness and Professions Code): NO. PARKING 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). �J CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDINd[- I hereby affirm that there is a construction lending agency C� for the performance of the work for which this permit is v 1� issued(Sec. 3097,Civ.C.). Lender's Name / 1 PROPOSED MAX. OCC, t`I� 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 a v -me ioned r erty for inspection purposes. If SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of ermittee Date S'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 'I hereby affirm that 1 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 APPLI CANT TO FILL IN BUILDING G" ADDRESS �f FiCertified copy is hereby furnished. BUILDING 9�si A �� p LOCALITY ADDRESS _ C- ECertified copy is filed with the county building inspection. LocwurY NEAREST `x department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P SSED BY CROSS ST. �� I O CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP /HIGHWAY Ro1��' 3 (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 / SIZE OF LOT EXISTING BLDG. C I certify that in the performance of the work for which this CD permit is issued,I shall not employ any person in any manner OWNERS.:)so as to become subject to the Workers' Compensation Laws. MAIL v OCCUPANCY GROUP-: �` o Date Applicant ADDRESS/'Zoe " - 7t4,,. S� PL{lSa�,� QMC/�^�' U TEL. W NOTICE TO APPLICANT: If, after making this Certificate of CITY No. 6 01 ZS-3 �'/6 OCCUPANT LOAD z 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 ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM El (LIST ITEMS BELOW) a 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 PROVIDED D 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 SIZEOF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE iness and Professions Code). FINAL APPROVAL 7 PRESENT USE OF BUILDING Ci 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 i ' 7044,Business and Professions Code). -t €,r- CONSTRUCTION LENDING AGENCY F ROPOSED USE of BUILDING �j`qC 4� +ir ( AN r Il i I hereby affirm that there is a construction lending agency S TQ I?- for the performance of the work for which this permit is issued(Sec. 3097,Civ.C:). C� R' CI.AJ 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 un n the ve-mentioned property spection purposes ` SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permitte Date WORKERS'COMPENSATION DECLARATION CE 875 (11-841 IC S TCE 875 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 ADDRESS Certified copy is hereby furnished. ING 0'`151 I�2 1-�s p C.' � LOCALITY ADDRESS a i"�h�5 IC.,V� I �iCertified copy is filed with the county building inspection�,IIUILO LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GR UP TYPE CESSED BY CROSS ST. �` O CONST. I CERTIFICATE OF EXEMPTION FROM WORKLEGAL �Jv COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NOOF 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 (SI00) 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 OWNER r�irry [j¢w@ fk- so as to become subject to the Workers' Compensation Laws. A _ I OCCUPANCY GROUP ' s! MIL X AD OR E55 33'� �t� Sl = Date .applicant / TEL.!•2 NOTICE TO APPLICANT: If, after making this Certificate of CITY SU�tck too ntLU No. L 71� -��• -0A4� 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 I No Spec. Knovvl. deemed revoked. _ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices _ I hereby affirm that I am licensed under provisions of Chapter - I 9 (commencing with Section 7000) of Division 3 of the Bust SAFETY PERMIT (LIST ITEMS BELOW) . NO. OF EXITS ness and Professions Code, and my license is in full force and j effect. PARKING REO�D PROVIDED �— 1 SPACES License Number Lie. Class LIMITED TIME USE T Contractor Date - OATE DATE y Z ❑ FROM: TO: I am exempt from the licensing -eauirements as I am a Licensed archiiec: or a registered professional engineer SIZE OF NO. OF INSPECTOR'S actino in my professional caraciiy (Section 70-51, Btis- ._ EXISTING BLDG. STORIES SIGNATURE inessand Professions Codel. FINAL APPROVAL PRESENT USE OF BUILDING Lie.or Reg. No. Date I "ri HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that l am exempt from the Contractor's License Law for the foflo«ing reason (Section 7031.5, Busi- ^ i:itiii ness and Professions Code): NO. PARKING ^ L ❑ SPACES PROVIDED /A iI ~I..3,`:i {, .''1•i •-. 1, as owner of the property. will do the %vork and the UIr structure is not intended or offered for sale (Section 7044.Business and Professions Code). CONSTRICTION 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.C.). Lender's Name PROPOSED MAX. OCC. Lender's_Address PERMIT FEE Z Oo 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 lasts relating to building construction, and herebv authorize representatives of this County to enter TOTAL FEE �5 G"() upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ` Si^nantre of Perrnit-ee Date 1`oRI:L12sCOMPENSATION DECLARATION 4 CE 87a It t-aa) MISCELLANEOUS APPLICATION ce al 1 bzrei / affirm that I have a certificate of consent to self COUNTY OF LOS .ANGELES BUILDING AND SAFETY DIVISION insurF..;jr'a(eftificate ofWorkers'Compensation Insurance.or a certified copy thereof iSec. =800.Lab.C.). Policy No. _Company — ! FOR APPLICANT TO F LL IN ADDRESS` �L 7 ❑ Certified copy is hereby furnished. X BUILDING "l✓ ���� Dr. LOCALITY ADOR ESSr / I J ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. Temple City CROSS ST. Date _:1p Ilr lllt NEAREST DISTRICT NCO. GROUP TYPE P ESSED BY p CROSS ST. Oak • �/, CONST. CERTIFICATE OF E\E>IPTION FRO)I'.PORKERS' LEGAL 1 COMPENSATION( INSURANCE OESCRIPT ON LOT NO. (BLOCK HOP (G`R`EY) STATE MAJOR SECOND LOCAL 1 NO. OF BLDGS. (This section need not be completed If tI1P l'OCkIm'olveti {-RACE NOW ON LOT 1USE ZONE SPE C:AL CONDITIONS by the permit is for one hundred dollars 61001 or less.) USE OF i SIDE OF LOT EXISTING BLDG. I certify that in the performance '-I :he ••co-4 "or 'which -his - permit is issued. I shall not emplov any ne.son in any manner OWNER ttYr �tq/Ly to so as to become suhiect ;o the ).Porkers' Coni^pensation LaFvs. AIL / OCCUPANC`' 3ROUP ADDRESS-33 �oUYCFI x5:1 - ! Date _ 1pplicant —. ---- NOTICE Tr) .1PPLIC.INT: If. ai; makinL :! s cate of $J C:r. D / N°� 3/0-3 3-0��8 OCCUPcN� LOAD Exemption, you diould become ubiect :o ;lie Workers* .c Compensation pro%isions of the Labe- _'ode. _k'(u must forth-4PDUCATiON F =X!T ( with coniniv with Bich nrovis:ori; l.. .his "ermit shall be I-RAIL_R ;ISE � GEOLOGY :NSP'_=cN No Spec. I<nC ,li. I deemed -' LICENSED CONTRACTORS RAC TORS DECL.AR.a 1IO', OCC:JPANCY INSPECTION� (-TIC Devices ❑ I hereby affirm :hat I am !icensed under prcvi51Unso-Chapter SAFETY PERMIT (LIST ITEMS BELO:'/� t 9 1cotmmenr'mg with Section 000) of Division of the Bust- NO. OF EXITS ness and P-ofessions Code. and me license is in ull fore: :and effect. az7 G- I PARKING SPACES REO.O �I PRO'J — License Number Lic. C!ass w U LIMITED TIME USE NCul' ntractnr___.--- Dai W N m ❑ m I am escpt frothe Lrznsin_ teyu uent :I tens I am .1 a l licensed architect or a egistzred prnfessional engineer SIZE OF NG. of NSPECTOR s .fie,;i Il:t EXISTING BLDG, "DRIES SIGs TORE z actinc in m protes;icnal :ac ir_ o:! . 13us- 0 iness Lind P-ofessicns Codel. FINAL APPROVAL - Jnq ccENT USE OF BUILDING Lie.or Rea. NII.---- — D:ite - HOME LDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's ( License Laufor the following reason (Section 7031.=. Busi- ness and P-otessions Code): NO. PARKING ❑ 'PACES PROVIDED I, as owner of the property. will do the work and the structure is not intended or offered for ;ale Section 1 7044. Business and Professions Code). X PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction tending :wency 1 for the performance of the �%ork for %khich this permit is I , issued (Ser. 3097,Civ. C.). }?::,:I Lender's Name a _ PROPOSED MAX. OCC. („I Lender's Address „la� 00 [ certify that t have read this application and ,tate that the PERMIT FEE 25. aboveinformation is correct. I agree to comply with all County ISSUANCE FEE rT1 ordin:mces and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25.00T rrl 1 upon the above-ment' Ilpzrty for inspection purposes. SEE REVERSE 1-OR EXPLANATORY LANGUAGE f'=' lenature of Permittee Date -`"''