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Home My Public Portal About9465 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 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.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ' ADDRESS ❑ Certified copy is hereby furnished. BUILDINGl LOCALITY ADDRESS ❑ Certified copy is filed with the county building inspection q r. NEAREST / department. L ALITY CROSS ST. Date - Applicant NEAREST DISTRICT NO, GR UP TYPE PROC SSED BY CROSS ST. CON CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY } NO. (CIRCLE) STATE MAJOR SECOND LOCAL IZ NO. OF BLDGS. (This section need not be completed if the work InVO1Ved TRACT NOW ON LOT USE ZONE .SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG.. I certify thatAn the performance of the work for which thisQ permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. ILUJ t(�t1�- OCCUPANCY GROUP AD DRE S Sl 4 '3 Date Applicant TEL: z NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. 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❑ No Spec. Knowl. deemed revoked. Panic Devices ❑ LICENSED CONTRACTORS DECLARATION occupprvcY wsPEcnoN' I hdreby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 REO'D D PROVIDED D A License Number Lie.Class LIMITED TIME USE Contractor— Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: TD: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXIS ING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVALIle \� RESENT USE OF BUILDING Lie.or Reg.No. Date - HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE z58G8A I hereby affirm that, I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- #'o 0 0 o,88 ness and Professions Code): NO. PARKING SPACES PROVIDED ^ � ❑ I,'as owner of the property, will do the work and the 0"1 0 0 0 0 0 o z structure is not intended or offered for sale (Section 1 7044, Business and Professions Code): r^ IO,Q7=83 ROPOSED USE'OF BUILDING • t CONSTRUCTION LENDING AGENCY ' I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.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, and hereby uth presentatives of this County to enter TOTAL Fee / ,e upon a ab ve men ncd property for insp�n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permi'f4e Date WORKERS'COMPENSATION DECLARATION 76 44 (2-80) MISCELLANEOUS APDL)CATION 1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof-(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING �— ADDRESS . 29 Certified copy is hereby furnished. uILD IN LOCALITY I , ADDRFS5 `�S V'\ �.�,� Certified.copy is filed with the county building inspection 1, NEAREST department. LOCALITY 1 t �`. CROSS ST. Date Applicant N AREST S U DISTRICT NO. GR P TYPE PRO SSED BY ROSS ST. �.. CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ! " DESCRIPTION LOT NO. BLOCK COMPENSATION INSURANCE MAP /y HIGHWAY NO. (J (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. � � (This section need.not be completed if the work involved TRACT NOW ON LOT USE ZONE SPEICIAL CONDITIONS `y by the permit is for one hundred dollars ($100) or less.) USE OF U SIZE OF LOT EXISTING BLDG. /D I certify that in the performance of the work for which this (� 0' permit is issued, I shall not employ any person in any manner OWNERZVNC_ t tis so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP �� 0 r_ W AD D RESS114(os yt2s rs. Date �G Applicant �/(�' r,/r/T i t 1 TEL.ai' {l V V LI NOTICE TO APPLICANT: If, after making this Certificate of, clry TE (� OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION EJ ❑ No Spec. Knowl. deemed revoked. Panic DBVIC@S ❑ ' LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION _A hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT � f (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000) of Division 3 of the Busi- El ness and Professions Code, and my license is in full force and PARKING. /,effect. SPACES REO'D O PROVIDED .� License Number Lic.Class • LIMITED TIME USE Contractor Date DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or, a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting In my professional capacity (Section 7051, Bus- EX TING BLDG. STORIES SIGNATURE 1neSS and Professions Code). PRESENT USE OF BUILDING y FINAL APPROVAL. Lic.or Reg.No. Date G• (� HOME OWNER-BUILDER DECLARATION NO. of EXISTING BUILDINGS ON LOT AND USE , I hereby affirm that, I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING t '$ 9 SPACES PROVIDED :2-5Z 3.9 A DI, as owner of the property, will do the work and the I •o structure is not intended or offered for sale Section ;#I oo , s '88 7.044, Business and Professions Code). ( o I o 0 0 o f o 1 o z ROPOSED USE OF BUILDING �pf ✓ CONSTRUCTION LENDING AGENCY _ / O'9,2'b`—.8 3 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. 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 u n the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ?— Zy--t-7 Signatur of Permittee Date . WORKERS'C PENSATION DECLARATION �E$454(2-80) M I SC E L LA N EO u S APPLICATION I hereby affirm that I have 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 APPLICANTTO FILL IN BUDDING ADDREEl SS 7� Certified copy is hereby furnished. oDRESS ' i IS, T1kA/ LOCALITY F1 Certified copy is filed with the county building inspection N NEAREST department. LOCALITY CROSS ST. Date' Applicant NEAREST DISTRICT NO. GR UP TYPE PROCESSED BY CROSS ST.• - CONST. DESCRIPTION CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL LOT NO. BLOCK MAP HIGHWAY COMPENSATION INSURANCE NO. (CIRCLE) STATE MAJOR SECOND LOCAL O_ ^ (This SCCt10R need.not be completed if the work1nVOIVed TRACT NO. OF BLDGS.NOW ON LOT USE ZONE SPECIAL CONDITIONS 0 by the permit is for one hundred, dollars ($100) or less.) USE of U JMA ZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this gqaI, .permit is issued, I shall not employ any person,in any mannerWNER t`1 b6 K N so as to become subject to the Workers' Compensation Laws. IL I! y OCCUPANCY GROUP �� V Date Applicant DOREss 16 0, S RS in z TEL. NOTICE TO APPLICANT: If, after making this Certificate oflrvT ` No. �_ OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICA ION 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 d ❑. NO Spec. KnOWI. deemed revoked. ❑❑ occuPANcv INSPEcrio LICENSED CONTRACTORS DECLARATION ni Panic Devices rI hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (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 PROVIDED 1_icense Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer. SIZE OF NO. of FRDM. TO: IrvsPEcroR's acting in my professional capacity (Section 7051, Bus- E 95TING BLDG. STORIES SIGNATURE iness and Professions Code). /� RESENT USE OF BUILDING {J� FINAL APPROVAL ^•�Oe � f�„� Lic.or Reg.No. Date HOME.OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE 1, hereby affirm that I am exempt from the Contractor's 5'8 2 5 A License Law for the following reason (Section 7031.5, Busi- . ness and Professions Code): No. PARKING # 1 4 0 ' SPACES PROVIDED O O O O EJ-I, as owner of the property, will do the work and the . I structure is not intended or offered for sale (Section o I o f o 0 0 0 0 7044, Business and Professions Code). / r . PROPOSED USE OF BUILDING , 90+ci i ,� CONSTRUCTION LENDING AGENCY S ed Or&24—.8 2 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 - 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 a d.hereby authorize representatives of this County to enter pon th bove-mentioned roper y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign re of PermVtee Date WORKERS'COMPENSATION DECLARATION 76 44 (2-80) MISCELLANEOUS A tl P L I C A T I O ® , 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 FO PLICANT TO FILL IN BUILD:NG / ADDRESS ❑ Certified copy Is hereby furnished. BUILDINGLOCALITY DRESS - Certified copy is filed with the county building inspection � NEAREST department. LOCALITY CROSS ST. Date - Applicant NEAREST DISTRICT NO. I GROUP TYPE 1PROCE SED B.Y CROSS ST. V D q CONST.' CERTIFICATE OF EXEMPTION FROM WORKERS', LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCKJ1 AAP HIGHWAY STATE MAJOR SECOND LOCAL } NO. OF BLDGS. 06 (CIRCLE) (This section need not be completed-if the-work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS. O by the permit is for one hundred dollars ($100) or less.) U USE OF IZE OF LOT EXISTING BLDG. G / cc I certify that in the performance of the work for which this O permit is issued, I shall not employ any person in any manner WNER. I- so as to become subject to the Workers' Compensation Laws. AIL DR OCCUPANCY GROUP ! S� W DDRES d /(� Date Applicant Cn TEL. OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of ITY� No. Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must•forth- APP CATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE(:] GEOLOGY INSPECTION deemed revoked. ❑ No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION. OCCUPANCY INSPECTION❑ Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 E= PROVIDED O License Number Lic.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 INSPECTOR'S acting In my professional capacity (Section 7051, Bus- XISTING BLDG. STORIES SIGNATURE iness and Professions Code). F �r PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date t HOME OWNER-13UILDER 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 201,035A )• SPACES PROVIDED ❑ 1, as owner of the property, will do the work and the I #'o o;o 0"4,O structure is not intended or:offered for sale (Section 7044, Business and Professions Code). 1 ROPOSED USE OF BUILDING X77 � O;O O O O O'Oa CONSTRUCTION,LENDING AGENCY 0:6 2'2—8 1 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 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 po/n above-me 'oned property for inspection purposes. SEE REVERSLVFORE PLANATORY LANGUAGE IVP �fi� A✓� �''�iJ �/ - _ YSignature of Permittee -Date ` WQRKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPL9CATION 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. BUILDING Company FOR APPLICANT TO FILL IN ADDRESS ❑ .Certified copy is hereby furnished. UILDING / LOCALITY �! ADDRESS / Certified copy is filed with the county building inspection �I NEAREST department. LOCALITY cRoss sr. Date Applicant. NEAREST DISTRICT NO/// I GROUP ITYPE PROC SSEI?_BY CROSS ST. �(O CONST, f y CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL IV/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. OF BLDGS. No'. ®O (CIRCLE.) a (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.) U .USE.TI ZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this t_ permit is issued,, I shall not employ any person in any manner NER `ek bbA&1 K i— L G so as to become subject to the Workers' Compensation Laws. ASL /yl OCCUPANCY GROUP 1 P —Z w ORE5Sg I _ W Date Applicant N TEL. NOTICE TO APPLICANT: If, after making this Certificate of IT No. 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 USEGEOLOGY INSPECTION [JElNo Spec. Knowl. ❑ deemed revoked. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic D8VIC2S❑ I hereby affirm that I am licensed under provisions of.Chapter SAFETY PERMIT ❑ (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 REO'D 'PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: El1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer gIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- XISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL y/ RESENT 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, _ GOO SPACES PROVIDED z 1, as owner of the property, will do the work and the structure is not intended or offered for.sale (Sectio ` #.0 0,0 o 4.0 . 7044, Business and Professions Code). PROPOSED USE OF BUILDING (r-- �0.0 0 0 0 0.0 z CONSTRUCTION LENDING AGENCY J I hereby affirm that there is a construction lending agency 0`6 2 2'—8 1 for the performance of the work for which this perinit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, a hereby uthorize representatives of this County to enter roTAL FEE u on the ve-mentioned roperty for inspection purposes. SEE REVERSE 'OR EXPLANATORY LANGUAGE 6—/�-�✓ 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 insuri�or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab.C.) n +, Policy No. Company FO WAPPLICANT TO FILL IN ABUILDREING IT DDSS Certified copy is hereby furnished. uILDING / LOCALITY ' A 'DRESS b Certified copy is filed with the county building inspectionNEwREsr department. LocnurY T �,` CROSS ST. Date Applicant NEAREST DISTRICT NO. I GROUP ITYPE PROCE ED BY CROSS ST.. GzI. �S.�Or — - CONST. / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (lJrr L/ DESCRIPTION LOT NO. BLOCK COMPENSATION INSURANCE "AP 067 PIG iWAV STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO..OF.BLD GS. (This SOCtIOn need not be completed if the.work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS Q by the permit is for one hundred dollars ($100) or.less.) U USE OF C I certify that in the performance of the work for which thistAIL S E OF LOT EXISTING BLDG. 0 permit is issued, I shall not employ any person in any mannerER �� F so as,to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP j�� 0ESS�7W t/ LLDate Applicant A ZNOTICE TO APPLICANT: If, after making this Certificate of C pl7� N0. 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 ❑ ❑ 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) 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 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 INSPECTOR'S acting in my professional capacity (Section 7051, Bus- (STING BLDG. STORIES SIGNATURE iness and Professions Code). –.� FINAL APPROVAL RESENT USE OF BUILDING � Lie.or Reg.No. Date r/ NO.OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION V 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 EJ l I, as owner of the property, will do the work and the #'oJa}o 4'0 structure is not intended or offered for sale (Section 7044, Business and Professions Code). /) o.m o 0 0,0 0.2 ROPOSED USE OF BUILDING //Jr)��` �I I , , CONSTRUCTION'LENDING AGENCY .0,6,2 9—8,1 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 I AJ 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 a d hereb authorize representatives of this County.to enter pon th bove- en t' ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE do Sig—nature of Permittee Date WORKERS'COMPENSATION DECLARATION 76 44 (2-801 MISCELLANEOUS A P P L 9 C A a I®N I hereby affirm that I have a certificate of consent to self COUNTY'OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or'a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING may, - - ADDRESS ❑ , Certified copy is hereby furnished. BUILDING ��f 5 _ ADDRF'SS 5 V LOCALITY Certified copy is filed with the county building inspection NEAREST 'LOCALITY / department." CROSS ST.- / Date -Applicant NEAREST DISTRICT NO. GROUP .TYPE 1PROCESSED BY CROSS ST. CONST.,. , CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I/f `mil COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP qHIGHWAY 0;Q PU 7 STATE.MAJOR SECOND-LOCAL (This section need not be completed if the Work involved - NO. OF BLDGS. USE ZONE SPECIAL CONDITIONS - l p TRACT - NOW ON LOT by the permit is for one hundred dollars {$100) or less.) USE'OF SIZE OF LOT EXISTING BLDG. C•" jr • �'' I certify that in the performance of the work for which this. permit is issued, I shall not employ any person in any manner . owrvER�L VM OU so as to become.subject to-the Workers' Compensation Laws. n �O / OCCUPANCY GROUP - MAIL. w ADDRESS KJ11{i � a Date Applicant, - TEL. NOTICE TO APPLICANT: If, after making this Certificate of clTy �� rvo. OCCUPANT LOAD Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply. with such provisions or this permit. shall be TRAILER USE GEOLOGY INSPECTION ' ❑ ❑ No Spec. Knowl: 0 deemed revoked. PanIC Devic es 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- I No. OF EXITS ness and Professions Code, and.my license is in full force and PARKING. effect. SPACES REO'D PROVIDED ' ' License Number Lic.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. OFINSPE INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL J PRESENT USE OF BUILDINGAA Lic.or'Reg:No. Date c —7EX HOME OWNER-BUILDER DECLARATION NO. of ON LOT AND ANDTING BUILDINGS USE I. hereby affirm that, I am, exempt from the Contractor's License Law for the following.reason (Section 7031:5, Busi- DO 3 2.6 A ness and Professions Code): NO. PARKING SPACES PROVIDED' ti,� I, as owner of the property, will do the work and the # o ofo c 88 ` structure ,is not intended' or offered for sale (Section 7044, Business and Professions Code). ' 0 0.0 0 0 0 0 PROPOSED USE OF BUILDING I� /) a CONSTRUCTION LENDING AGENCY ) 0.7,.1'4'-81 I hereby affirm,that there is a construction lending agency for the performance of the work for wvhich this permit is issued(Sec. 3097,Civ:C.). Lender's Name PROPOSED MAX. OCC. - - Lender's.Address` PERMIT FEE 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, TOTAL FEE �C tJ s hereb authorize resentatives of,this County to enter oqe-m nt A114 property for spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE, P Itt a Date V WORKERS* COMPENSATION DECLARATION CE875 ill aa) MISCELLANEOUS APPLICATION a�� I herebv affirm that I have a certificate of consent to self i insure. or a certificate of\\orkers'Compensation Insurance.orCOUNTY OF LOS .ANGELES BUILDING .AND SAFETY DIVISION �" )I a certified copy thereof(Sec. 3800. Lab.C.). / — Polio No._ _ComnanyFOR APPLICANT TO FILL IN 4 DRESS FICertified copy is hereby furnished. BUILDING �TO S T+�NgLOCALITY P1�, LocArY 7G AO DR ESS -A 1 Certified copy is filed with the count, building inspection LOCALITY Temple NEAREST department. City CROSS ST. Date NEAREST DISTR CT NO G UP TYPE de ESSED BY CROSS ST. �jLC lJ O / CONST i CERTIFICATE OF ESENIPTIO\ FROM 'AORKE-RS' LEGAL COMPENSATION INSI, RANGE OESCR IPT!ON LOT NO. �SLCCK IMA GRW AY NO. OF BLDGS. 1I0. (CIRCLE) STATE MAJOR SECOND LOCAL ( (This section need not be completed of the \fork Involved -RAC' '40W ON LOT USE ?ONE SPECIAL CONDITIONS by the permit is for one hundred dollars +5100) or less.l USE OF t SIZE OF LOT EXISTING BLOC. I certify that in the oerfonnance �f �!te 'warl 'or •chiC!l -his 777ILU Permit is issued. I ;hall not emPle any aersoU in any manner OWNER 6 46E C17r 'R- TUAr 362041?C so as to become subject ;o the `\orkers' C,mlpensation Laws' MA1 OCCUPANC ;ROUP IL I� t Date —_ Applicant MAL ESS (300E- . M4-,(NST . .0 210 NOTICE TO APPLICANT: If. elite: makinL• ''li> i-erri-lic;lte ,t elr- ALHA04t3RANO. OCCUPaIu- LOAD Exemotio-7. you <Ilotild become subiect -o he \\., 11 Compensation provisions of tic Labor .:,lde, you must forth- I APDLICATICN FDR HA�rI,:s=F i with compiy pith <Uch ^revisions or .his '-ermit shail be -RAILER SSE 11 GEOLOGY :NSPECT!CN — NO SLBC. Kna:ll r i deemed:e eked. — L✓ LICENSED CONI RACTORS DECLARATION' OCCUPANCY INSPECTION Panic Dev;ces I hereby affirm that l am licensed under DCC7'153UmS JI(I111Jt:L SAFETY PERMIT ` LIST ITEMS BELOW) a 9 (commencing with Section �()�� of Dlllsion J ) tile BuFI- NO. OF EXITS ness and P-ofessions Code. and my license is in fuil force and effect. PARKINGj SPO CES REO'O 1 I PROVIDED _ License Number Lic. Class LIMITED TIME USE w Contractor Date _ DATE OA-E y I am exempt from the licensing requirements as I am .I TO m i licensed architect or a re_istered nr(1feSsional engineer SIZE OF NO, of INSPECTOR'S z actins in my prof,•r.sional :aracin_' ,;ioa _051. Bus- EXISTING BLDG. -OR 1 S"AT 9 inessani l' ufessicnS(adcl. FINAL APPROVAL /0n � U "RESENT USE OF BUILDING _ LIC. Or Rea. NII. _ HOME O\\NI R-BUILDER DEC�LARAHON NO. OF EXISTING BUILDINGS �J) ON LOT AND USE - V ^ II�:.f. S I'•II! - I hereby alTirnl that l am exempt from the Contractors ` O License Law for the followine reason 'Section _931._. Busi- ness and ProiessionsCode): NO. PARKING SPACES PROVIDED 1, as owner of the propertywill do the work and the stnieture is not intended or offered for :ale (Section t 7044. IIIISilICSS and Professions Code). CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING 'I hereby affinil that there is a construction lending ;wencv l h (GLt l ro Q k ,�'LUI otC • for the performance of the .cork for which this permit is issued(Sec. 3097•Civ. C.). $ p Lenticr's Name. -- _ KVaai x•14 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 Couniy ISSUANCE FEE ordinances and State last's relating to buildinL construction. and herebv authorize representatives of this County to ent.cr TOTAL FEE 25.00 t upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGU-\GE 1 Si 1/ahue Permittee Date 7 1 WORKERS' COMPENSATION DECLARATION p0-0063DPW12/90 M15C.ELLANEOUS APPLICATION I. hereby affirm that I havea certificate of consent to self COUNTY OF LOS ANGELES BUILDING.AND SAFETY DIVISION ' insure, or a certificate of,Wdrkers'Compensation Insurance, or ' a certified copy thereof (Sec.3800, Lab. C.)• 11 ' Policy'No. Company FOR APPLICANT TO FILL IN BUILDING BLI D,I�'! DRE5I5`C p� ( ADDRESS ❑ Certified copy.is hereby;furnished. g 'Y t'1'� H'S P/` LOCALITY ❑ Certified copy is filed with the county building inspection CI �� n�� zip I �� NEAREST department. CROSS ST. Date - Applicant SIZE OF LO NO.OF BLD S.NOW ON LOT DISTRICT NO. J.GROUP TYPE PROCESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS' colvsT. C TRACT BLOCK LOT NO. I .. .COMPENSATION INSURANCE S p 0I NOP (CIRCLE) STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOKPAGE PARCEL USEZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) I.certify that in the performance.of the work for which this I�Gym- `{5 TEL No. permit is issued. I shall not employ any person in any manner `" �f so as to become subject to the Workers' Compensation Laws. ADDRESS OCCUPANCY GROUP tr r Date Applicant CITY zIP — NOTICE TO APPLICANT: If; after making this Certificate OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR Compensation provisions of the Labor Code.you must forthwith EXIT HARDWARE: comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ 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 Business NO.OF EXITS Nam SIL and and Professions Code.and my license is in full force and effect. ev • PARKING• License Number Lic. Class REQ'D PROVIDED SPACES I Contractor Date LIMITED TIME USE ElI am exempt from the licensing requirements as I am a DATE DATE licensed architect or a registered professional engineer FROM: To: acting in my professional capacity(Section 7051, Business SIZE OI F BLDG. S.OF ES INSPECTOR'S SIGNATURE. and Professions Code). Lic. or Reg. No. - Date PRESENT 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, Business 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, PROPOSED USE OF BUILDING Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PROPOSED MAX.OCC. 1 (Sec. 3097, Civ. C.). Lender's Name APPLICALNT(PRINT) Z J� _ TEL No. .' 6L6 66 Lender's Address ADDRESS I certify that I have read this application and state that the above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes. - - TOTAL FEE I g l 7D�D3 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature or Permittee Date