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HomeMy Public PortalAbout9519-9521 LAS TUNAS DR_Miscellaneous__ WQ KERS'COMPENSATION DECLARATION CE 875(2-80) M I S C E L LA N E®U SAPPLICATION I hereby'affirm that I have a certificate.of consent to self insus-e, or a certificate of Workers'Compensation Insurance,or COUNTY Y ®F LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILD:NG / ADDRESS Certified copy is hereby furnished. BUILDING ADDRESS 9 1 al LAS�VIV FIs �Tcr LOCALITY Certified copy.is filed with the county building inspection NEAREST department. LOCALITY t�L �� ( /'�'�' ( �',� ���� CROSS ST. Date Applicant NEAREST, n 111 \_l� V� DISTRICT GR UP TYPE PROCE SED BY CROSS ST. i (/ —� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DEsc R IPT ION Lor NO. BLOCKMAP ^/ d / HIGHWAY. NO. Oma. t (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. a (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE J SPECIAL CONDITIONS ' Q by the permit is for one hundred dollars ($100) or less.) USE OF Gam ' I certt� ify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. 0 permit is issued, I shall not employ any person in any manner OWNER VepWoNj �J a .so as to become subject to the Workers' Compensation Laws. MAIL ,Y OCCUPANCY GROUP �� 0 ADDRESS LU L� '-WAS D�, ll�� a Date Applicant , TE U) NOTICE TO APPLICANT: If, after making this Certificate of CITY ry .�t3 ��S OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLI ATION FOR EXIT HARDWARE:' with comply with such provisions or this permit .shall be TRAILER USE❑ GEOLOGY INSPECTION❑' No Spec. Knowl. ❑ deemed revoked. P8111C DEVICES � I LICENSED CONTRACTORS DECLARATION occuPwrvcY IrvsPEcrloN❑ I hereby affirm that 1 am'licensed under provisions of Chapter SAFETY PERMIT I (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 effect. PARKINGSPACES REO'D O PROVIDED D License Number tic.Class LIMITED TIME USE Contractor Date DATE DATE, FROM: To. Ell am exempt from the licensing requirements as Lam,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 SIGNATURE IneSS and P[OfeSS10RS Code). PRESENT U.SE OF BUILDING FINAL APPROVAL tic.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- NO. PARKING 0 3 8 8'A. ' ness and Professions Code): SPACES'PROVIDED ' OI, as .owner. of the property, will do 'the work and the # o o',o o 88 structure is not intended or offered' for sale (Section ' 7044, Business and Professions Code). -PROPOSED USE OF BUILDING 1 , CONSTRUCTION LENDING AGENCY J O�M1! 0 7. 1 7-8-1. 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.). l� Lender's Name _ PROPOSED MAX. OCC. - Lender's Address PERMIT FEE certify that ave read thLn and state that the above I mply with all County ISSUANGE'FEE ordinances State lauilding construction, TOTAL FEE.:25:,0 /� and here th represthis County to enter Vpo e ab oned inspectiof pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE S Signature A Permittee ate l WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APrLICATION • 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. CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS /l 1' ❑ Certified copy is hereby furnished. FOR ADDRESS 952,1as Tunas Dr..=Suite 4 Certified copy is filed with the county building inspectionNEAREST r' department.. LOCALITY Temple City, Ca'. ' CROSS ST. Date Applicant _ NEAREST. - DISTRICT NO. GROUP TYPE PRO SSED CROSS ST. ,^ CONS'1!_ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �1 ✓� '/ COMPENSATION INSURANCE DESCRIPT10N LOT NO. BLOCK MAP AAJ HIGHWAY } No. cave (CIRCLE) STATE MAJOR SECOND LOCAL d NO. OF BLDGS. O (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. 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 L OWNER Vernon C .. Newton F- so as to become subject to the Workers', Compensation Laws. MAILOCCUPANCY GROUPLU rr ADDRESS24'2 Newport Dr. a Date Applicantto TEL NOTICE TO APPLICANT: If, after'making this Certificate of -,f,-CITY Palm :Springs , N,.'(714)328-7422 . 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 C] 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) 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 effect. PARKING' REQ 13 U PROVIDED - � SPACES .' 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- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). C. PRESENT USE OF BUILDING Office of ZIOs FINAL APPROVAL Lic.or Reg.No. Date Angeles Retired Fire & Police HOME OWNER-BUILDER DECLARATION NO..OF EXISTING BUILDINGS Assoc 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- NO.PARKING ness and Professions Code):., SPACES PROVIDED ❑ I, as owner of the property, will do the work and the z 1 .4 U 1 A structure is not intended ,or offered, for sale (Section 7044, Business and Professions Code). # 0.0.0 o 8 8 PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 0110 0 0 0 0 o z I hereby affirm that there is a construction lending agency for the performance of the work for which'this permit is 0,0 6-8 1 issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. ' Lender's Address PE mI 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, —0^ Non Profit and hereby authorize representatives of this County to enter r_T.OTA'L'• •FEE upon the above- enti ed prope for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ,ctob,er 1, 1981 �. Si ure of ermittee Date .fi• Wq,RK.RS'COMPENSATION DECLARATION 76 44 (2-80) MISCELLANEOUS APPLICATION 'CEI hereby a certhat I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' rs'Compensation Insurance,or' , 'a certified copy thereof(Sec. 3800,Lab.C.) Policy No. BUILDING Company FOR APPLICANT TO.FILL IN wDDREss s' ❑ Certified copy is hereby furnished. il BUILDING �'� i AcaT� � LOCALITY ADDRESS lam. M .Certified copy is filed with the county building inspection NEAREST department. LOCALITY Tte$_A lit. ) CROSS'Sr. DateApplicant EAREsr YID-/�1 L_�,J DISTRI T y0., G UP TYPE PROCES D BY CROSS S T. ��.+V�/�+��/ J5— U/IaP 2 CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP O RIGRwAV >_' NO. (CIRCLE) STATE MAJOR SEC D LOCAL a NO. OF SLOGS. (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.) usE of //^•/ SIZE OF LOT EXISTING BLDG. 1 ,✓� I certify that in the performance of the work for which this vvV// 0 permit is issued, I shall not employ any person in any manner OWNER ��� ^��� H so as to become subject to the Workers' Compensation Laws. AAAIL OCCUPANCY GROUP LU U ADDRESS—1�'ct � c7 )`."-� J S�•�+t / a Date Applicant t) NOTICE TO APPLICANT: If, after making this Certificate of CITY� pZ�•��✓ N.L 3/SI 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. - LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ► t (LIST ITEMS BELOW) 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 REQ'D F-= 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 ST OF INSPECTOR'S acting-in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). RESENT USE OF BUILDING ���ICC. © F FINAL APPROVAL 1 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 ;91 9 7.3 A SPACES PROVIDED ' I, as owner of the property, will do the work and the # 0 0 0 088 structure is not intended or offered for sale (Section 7044, Business and Professions Code). _0 0 0 0 0 0 o z OPOSED USE OF �BUILDING f�'�//_ CONSTRUCTION LENDING AGENCY �Oc�Y� 0 5,0 2-8 5 I hereby affirm that there is a construction lending agency for the performance of the work for which this•permit isLJ> 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 and here authoriz re es of this County to enter oI. h Ove-men ion t for specti n purpose EE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permit ee Date WORKERS'COMPENSATION DECLARATION CE 8754(2-80) MISCELLANEOUS APPLICATION I herebe 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. BUILDING / .l n� y�Y�,v�C�J LOCALITY ' ADDRESS ❑ Certified copy is filed with the county building inspection /� //jj NEAREST department. LOCALITY C�. L� / �_I 0.4 C�/n� CROSS"ST. Date Applicant NEAREST e���/ �,/ VlY' / - DISTRICT N G OUP TYPE` 1PROZESED BY CROSS ST. L CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL' IRCC ( DESCRIPTION LOT NO. BLOCK COMPENSATION INSURANCE MAP Av' >_No. (c IRCLE) STATE MAJOR SECON LOCAL 0- NO. NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0 by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. 1 /� I certify that in the performance of the work for which this v 0 permit is issued, I shall not employ any person in any manner V OWNER > > J �� U so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUPfAAIL 11 AD DR ESS IL Date Applicant N TEL. z NOTICE TO APPLICANT: If, after,making this Certificate of CITY . NO. OCCUPANT LOAD 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. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic D@VICES ❑ I hereby-affirm that I am licensed under provisions of Chapter SAFETY PERMIT LI (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 License Number Lic.Class LIMITED TIME USE, ��JJ Contractor Date DATE DATE FROM: TO: ❑ I am exempt from the.licensing requirements as I am a. licensed architect or a registered professional engineer E OF NO. OF / INSPECTOR'S acting in my professional capacity (Section 7051, Bus- XISTING BLDG. V//�J STORIES SbGNATURE FINAL APPROVAL iness and Professions Code). 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 u License Law for the following reason (Section 7031.5, Busi- ness and PI'Ofe5510nS Code): NO.PARKINGSPACES PROVIDED ❑ 1, as. owner of the property, will do the work and therJ,�- S 9 A structure is`, not intended or offered for sale (Section }jj 7044, Business and Professions Code). ROPoseD USE OF BUILDING �t* 8 8� esfi; A CONSTRUCTION LENDING AGENCY' '8 b' I hereby affirm that there is a construction lending agency 07,30 . for.the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). _ Lender's Name PROPOSED MAX. Lender's Address PERMIT FEE p� 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 ordmanc an State law re in building construction, TOTAL FEE a eby a horiz re of this Fount to enter D r for ins eCtio pur os SEE REVERSE FOR EXPLANATORY LANGUAGE igI ature of Perini tee ///{ at " t7RRERS'COMPENSATION DECLARATION CE 875 (11-84) M I SC E L LA N EO U S 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.the1eof(Sec. 3800,Lab.C.). Policy No.7 Company FOR APPLICANT TO FILL IN BUILDING ADDRESS J FICertified co is hereby furnished. BUILDING � {L p copy y ADDRESS , LOCALITY 1 0 Certified copy is-filed with the county building inspection LOCALITY NEAREST l+ department. 7� CROSS ST. S Date Applicant NEAREST~ DIST ICT GROUP TYPE PR So ED BY CROSS ST. CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCKMAP'ZON.JSPECIAL �. HIGHWAY NO. CIRCLE STATE MAJOR SECOND LOCAL NO. OF BLD GS. (This section need not be completed if the work involved TRACT NOW ON LOT USE CONDITIONS by the permit is for one hundred dollars ($100) or less.) us- OF SIZE OF LOT EXISTINGLD . i d 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 OWNER 4.11 so as to become subject to the Workers' Compensation Laws. MAIL p. .�► OCCUPANCY GROUP o ADDRESS 13 Date Applicant `S ��TEL. �. LWIJ NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. jj jS S�/3 OCCUPANT LOAD Exemption, you should become subject to the Workers' AP ICATION 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. Know[. 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- a 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 S , C DATE DATE I am exempt from the licensing requirements as I am a R licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S NATURE iness and Professions Code). RESENT USE OF BUIL G FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS NO 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 and Professions Code): NO.PARKING �1 —QQ�1 S/ 9/89 I, as owner of the property, will do the work and the SPACES PROVIDED 50176 1 FM 1 structure is not intended or offered for sale (Section e 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF B DING 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 I ]V• u , 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 relati to building construction, ea! authorize repres t ves of this County to enter TOTAL FEE , pon the a ve-menti e ty for ins on llurpo SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee D to WORKERS'COMPENSATION DECLARATION CE 875(11-84) M I SC E L LA N E O U S APPLICATION • CE 875 I heieby affirm that 1 have a certificate of consent tself 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.Q. an BUILDING PolicyC No. Company y FOR APPLICANT TO FI LL IN ADDRESS E] Certified copy is hereby furnished. BUILDING / _ • �1 LOCALITY. ` z ADDRESS .CR .. F1 Certified copy is filed with the county building inspection GT y LOCALITY /• NEAREST / department. Tr_1-11-LTi cRoss sr. Date Applicant NEAREST DISTRIC NCj G OUP TYPE PR ESSED BY CROSS ST. deo CONST.1 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V 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 SIZE OF LOT EXISTING BLDG. / I certify that in the performance of the work for which this permit is issued, I shall not employ anyperson in any manner /� P P P OWNER L / b�/ Lt �TSf y so as to become subject to the Workers' Compensation Laws. MAIL � OCCUPANCY GROUP — o ADDRESS Mov / �`/' U Date Applicant I„ TEL. NOTICE TO APPLICANT: If, after making this Certificate of CITY No. — 3�1 OCCUPANT LOAD N Exemption, you 'should become subject to the Workers' ' z Compensation provisions of the Labor Code, you must.forth- APP L CATION FOR 247_S-9L/ 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 ❑ El 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 D SPACES License Number Lie. Class LIMITED TIME USE Contractor DateaA4 DATE DATE 0 I am exempt from the licensing requirements as I am a V I FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPE CTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness.andProfessions Code). �` FINAL APPROVAL 1�2 .L� - 9 PRESENT USE OF BUILDING ;J, < 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 SPACES PROVIDED 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). t CONSTRUCTION LENDING AGENCY PROFo.ED USE of BUILDING Ld�/J RRek I hereby affirm that there is a construction lending agency a 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 •C 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-m do d grope ty o�inspection purposes. i r SEE REVERSE FOR EXPLANATORY LANGUAGE I Signature of Per e Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) I SC E L LA N EO U S APPLICATION CE 875 I hereby affirm that, I have a certificate of consent to self COUNTY OF LOS ANGELES AUILDING AND SAFETY DIVISION insure, ar a.�ertificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDINGADDRESS Certified copy is hereby furnished. UILDING s,�, S a A- M C,# LOCALITY ADDRESS Certified copy is filed with the county building inspection OCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRI T NO. G OUP TYPE �//JJJ P CESSED BY CROSS ST.GAL 13-a CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL //JJ yr COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NOOF LDGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOW. ONBLOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) usE of A I certify that in the performance Of the work for which this SIZE OF LOT EXISTING BLDG. L permit is issued, I shall not employ any person in any manner OWNER � I� �'S �. 4 oy. �" C:) so as to become subject to the Workers' Compensation Laws. MAIL y �,gs ,� p,2 �r OCCUPANCY GROUPa o ADDRESS F- Date Applicant �r� /►=�f W NOTICE TO APPLICANT: If, after making this Certificate of CITY I ♦ L vI / NO.TEL. OCCUPANT LOAD CL_ Exemption, you should become subject to the Workers' z 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 ❑ El 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. PARKINGREQ'D E= 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 INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE iness and Professions Code). FINAL APPROVAL I PRESENT USE OF BUILDING 7 Lic.or Reg.No. Date �7 Y"FF-3s i OA-4-4-- O-F c,15-:1 1 1 FE HOME OWNER-BUILDER DECLARATION N6.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 :': i HSI a :sf 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 A r .1!-3,1,� JF for the pefformance of the work for which this permit,is issued(Sec. 3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address �1 I certify that I have read this application and state that the PERMIT FEE Oc 51 CC) above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State lays relating to building construction, and hereby authorize representatives of this County to enter TOTAL, FEE 51(� upon the above-mentioned property for inspection purposes. 1 X193 SEE REVERSE FOR EXPLANATORY LANGUAGE q��gnat.re �mittee Date