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HomeMy Public PortalAbout9607 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (2-80) MISCELLANEOUS APP`ICeTION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION iirsltce, 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. wBUDINGDOREss_ N CC LOCALITY ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. Date Applicant NEAREST DISTRI NO. UP TYPE ESSED BY CROSS ST. �© ON CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL IO ,;�I C COMPENSATION INSURANCE DESCRIPTION I LOT No. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL } NO. (CIRCLE) d 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 cc OF LOT EXISTITI NG 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 so as to become subject to the Workers' Compensation Laws. MAIL �( �//7{�� //�{( //�// OCCUPANCY GROUP `� W ADDRESS V � rwjlji n1i, `+r• �•f a Date Applicant �y �p� n ..���(}yL /� � NOTICE TO APPLICANT: If, after making this Certificate of CIT't' t �/Z TEL"f'01RJ>ffZ�� 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 INSPECTIONEl NO Spec. KnOVVI. Eldeemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 0 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'D PROVIDED 69,4/3 I , I ��r SPACES License Number Lie.Class (�1j//J�(W/ J` N 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 INSPEC R's acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG RE iness and Professions Code). /``�IId� FINAL APPROVAL c PRESENT USE OF BUILDING' �� �O/ Lie.or Reg.No. Date J HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that, I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): No. PARKING SPACES PROVIDED El1, 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). *- PROPOSED USE OF BUILDING 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, TOTAL FEE and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date E WORKERS'COMPENSATION DECLARATION CE 875 (2-80) APPLICATION MISCELLANEOUS CE 875 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab. C.) BUILDING /j Policy No. Company FOR APPLICANT TO FILL IN 7 IE,pDD RESS (/ ❑ Certified copy is hereby furnished: BUILDRESSING LOCALITY �— ❑ '. D ��0��4.45 / !/�VG�".7 �L�• /-C Certified copy is filed with the county building inspection NEAREST department. LOCALITY Z_—,,7 � /7 J�� �v cRoss ST. 7", e Date Applicant NEAREST �r DISTRICT NO. GRO;U/P TYPE PROCE ED BY CROSS ST. Y ` CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O r DESCRIPTION LOT NO. BLOCK COMPENSATION INSURANCE HOP Lq gt� (CIRCLE) STATE MAJOR SECOND LOCAL ,- ((This t bcompleted if the work involved NO. OF BLDGS. 0 s section neenoe comp TRACT S NOW ON LOT USE ZONE SPECIAL CONDITIONS o by the permit is for one hundred dollars ($100) or less.) U SIZEOF LOT EXISTING BLDG. USE OF 111—.2— . ' I certify that in the performance of the work for which this X permit is issued, I shall not employ any person in any manner WNER (Orr bUlldth /�j o so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP A6 ra (� A DRESS /`--' lL Date- Applicant D s a s Certificate of TEL. / �/ - �-- OCCUPANT LOAD Z NOTICE TO APPLICANT: If, after making thiIry o. (p 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 1:1Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) E:19 (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. PARKINGSPACES REQ'D D PROVIDED License Number Lie.Class »��JJ 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). RESENT USE OF BUILDING ag'^ Ur FINAL APPROVAL 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. PARKINGSPACES PROVIDED Ell, as owner of the property, will do the work and the 20.521 A structure is not intended or offered for sale (Section' 7044, Business and Professions Code). OPOSED USE OF.BUILDING d/.? � # 0 0 0 0 8.8. CONSTRUCTION LENDING AGENCY 0 0 0 0 0 0 0 2 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 0 728-81 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 hereby authorize representatives of this County to enter u on above-me Toned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SiPermittee Date �/ WORKERS'COMPENSATION DECLARATION CE 875 (2-80) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS (� ❑ Certified copy is hereby furnished. BUILDING o OP LOCALITY ADDRESS ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY I CROSS ST. Date Applicant NEAREST DISTRICT NO. G UP TYPE / PR` SED BY CROSS ST. T �i //C/ _ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL C COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK Mac HIGHWAY STATE MAJOR SECON OCAL } NO. OF BLDGS. No. (CIRCLE)GLE) 0. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONEFCIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) ///��� U USE OF // -�j � SIZE OF LOT EXISTING BLDG. (v /V/I certify that in the performance of the work for which this 0 permit is issued, I shall not employ any person in any manner OWNER _� f'" so as to become subject to the Workers' Compensation Laws. MAIL Rlu r OCCUPANCY GROUP w ADDRESS d Date Applicant - N NOTICE TO APPLICANT: If, after making this Certificate of CITY t>° 'e CI 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 EJ 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 SPACES REq'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- EXISTING BLDG. STORIES S GNATU RE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL 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 SPACES PROVIDED ❑ I, as owner of the property, will do the work and the 3'7.b A structure is not intended or offered for sale (Section # o e o 0 8 8 7044, Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY o 0 0 0 0 0 o z 1 hereby affirm that there is a construction lending agency -Shoo 0 1. 17"85 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 and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date 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 �7 Certified copy is hereby furnished. BUILDING 9607 LAS TUNAS DR. LOCALITY ADDRESS ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY TEMPLE CITY Off, CROSS ST. v�y Date Applicant W NEAREST ROSEMEAD- BL. DISTRICT NO. GRO'P TYPE PROCESSED BY CROSS ST. �.�— Jf X/ /y CONS TI CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL !r, L, �"i v COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK N0. /I (ci C�/E) STATE MAJOR SECOND LOCAL a NO. OF BLDGS. �1 (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. I certify that in the performance of the work for which this \/ 0 permit is issued, I shall not employ any person in any manner OWNER MR.& MRS. A.W. DRIVER so as to become subject to the Workers'Compensation Laws. AIL OCCUPANCY GROUP UJ ADDRESS 9611 LAS TUNAS DR. CL Date Applicant TEL. 7` NOTICE TO APPLICANT: If, after making this Certificate of CITY TEMPLE 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 a GEOLOGY INSPECTIONEl7' 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 REO'D O PROVIDED D License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE } FROM: TO: Fi—,q-am exempt from the licensing requirements as I am a icensed 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). RESENT USE OF BUILDING FINAL APPROVAL d Lic.or Reg.No. Date BEAUTICIAN SHOP HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE 9 9.4 /�:5 ri ll I hereby affirm that, I am exempt from the Contractor's ro .J License Law for the following reason (Section 7031.5, Busi- # o:0 0 o 8,8 ness and Professions Code): No. PARKING SPACES PROVIDED 4 I ❑ I, as owner of the property, will do the work and the 0:0 ro 0 0 0 0 structure is not intended or offered for sale (Section 7044, Business and Professions Code). IA64ROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY BEAUTICIAN SHOP 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 $25 .00 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 $25 . 00 (Pay to City of Temple City) and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) + CE 875 MISCELLANEOUS A P P L I C A T I O 14 L � I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION dull my re, 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 LOCALITY DDRESS 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DIS TRIC G UP TYP PROCESSED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ` COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SEGO LOCAL NO. OF BLO65. (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 r SIZE OF LOT EXISTING BLDG. C 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 mannerOWNER y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUPlhi] o ADDRESS F•- Date Applicant C3 TEL. LLI .T NOTICE O APPLICANT: If, after making this Certificate of. CITY OCCUPANT LOAD No. z Exemption, you should become subject to the Workers' AP KATION FOR EXIT HARDWARE: _ Compensation provisions of the Labor Code, you must forth- _ LLQ 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. PARKIN G REQ'D PROVIDED SPACES License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ❑ 1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- 5XISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING i Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS i ON LOT AND USE I hereby affirm that I am exempt from the Contractor's 1 2 0.3 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING # o --0.0 8 8 I, as owner of the property, will do the work and the SPACES PROVIDED � 0 0 0 0 0 0 o z structure is not intended or offered for sale (Section ✓ 1 1,2 8-8 8 7044,Business and Professions Code). ✓� CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING V� I hereby affirm that there is a construction lending agency t 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 (.- 0 0PERMIT 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, fl anhereby authorize representatives of this County to enter TOTAL FEE (� upi n the abo nentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i Signature of Permittee 15ate WORKLRS'COMPENSATION DECLARATION 769444 MISCELLANEOUS APPLICATION ' 1 hereby affirm that 1 have a certificate of consent to self CE 875 (11-84)COUNTY OF LOS ANGEr,ES°'-' BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(See. 3800,Lab.C.). Policy No.-__Conlpany FOR APPLICANT TO FILL IN BUILDING ADDRESS D ADDRESS 5/�4 � FICertified copy is hereby furnished. BUILDING XX ADDRESS () LOCALITY Certified copy Is filed with the county building inspection LOCALITY NEAREST department. 3LX CROSS ST. Date_ Applicant —. NEAREST DIS W. TYPE P CESSED BY CROSS ST. o/ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' P LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK Naa Ric law AY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (Tills 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 BLDGv certify that in the performance of the work for which this D. permitis issued, I shall not employ any person in any manneXX OWNER of building so as to become suhjec•1 to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS L Date Applicant — LL NOTICE -1-0 APPLICANT: If, after making this Certificate of CITY _ `7t NoOCCUPANT z OCCUPANT LOAD C/ Exemption, you should become subject to the Workers' APPLIC TION FOR f EXIT HARDWARE: Compensrtiml 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. OCCUPANCY INSPECTION ❑ Panic Devices a I,ICENSF.0 CON"IRAChORS DECLARATION I hereby affnin that I ani 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 an*X effect. Name of business PARKING REO'D PROVIDED SPACES LL�� License Number Lic. Class � LIMITED TIME USE Contractor — Date DATE DATE FROM: TO: I am exempt fronr the licensing requirements as I am a licensed architect or a registered professional engineersaE of NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES sl A E iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL - Lic.or Reg. No. _Date — -14 1 WA Mq I HOME OWNER-BUILDI'.R DECLARATION No. of EXISTING BUILDINGS ON LOT AND USE I hereby affirm that l ani exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness mid Professions Lode): 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 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency Wit' for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). r Lender's Name PROPOSED MAx.'OCC. Lenders Address--_— -_._-- 1 PERMIT FEE 25 - 00. certify that I have read this application and state that the 'f` above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL. FEE 25 . 00 Upon the ahove-nient�el perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE --- �irnaiure I,f I'I•n littly )ate R'ORKERS'COMPENSATION DECLARATION CE 875 M ISCELLANEOUS APPLICATION �7 CE 875 (11-84) [_ ( I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 'IUI� 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 1499 ❑ Certified copy is hereby furnished. BUILDING LOCALITY - xx ADDRESS 6Q tCL4 ka Q. CSL ElCertified copy is filed with the county building inspection LOCALITY NF-AREST department. Xy. CROSS ST. ell Date— —Applicant NEAREST DISTRICT NO. GR rj UP TYPE CESSED BY CROSS ST, /^�� �/ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL C"ONIPENSAFION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. OF BLDGS. V. ICI.CLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (5100) or less.) USE of ///J SIZE OF LOT EXISTING BLDG. / p I certify that in the performance of the work for which this GGG.!!r D_ permit is issued, I shall not employ any person in any manneXX OWNER of buildingtri e so as to hcconlc subject to the Workers' Compensation Laws' MAIL OCCUPANCY GROUP ® ci ADDRESS ` i, U Date-- Applicant _ uJ r0- NOTICI: 1'O APPLICANT: If, after making this Certificate of clrr'–• �".� No. ;I, . r OCCUPANT LOAD 0_ Exemption, you should become subject to the Workers' APIQICATibN 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. Knowl. deemed revoked. ❑ L.IC'ENSED CUN"I RACl'ORS DECLARATION OCCUPANCY INSPECTION E] Panic Devices I hereby affirm that I ani licensed under provisions of Chapter SAFETY PERMIT E] (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 anix effect. Name of business PARKING SPACES REO'D E= PROVIDED License Nuniber _ 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 INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date IiOMI:OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGSi_i t-. ... ON LOT AND USE 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 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued fSec. 3097,Civ.C.). Lender's Name PROPOSED MAX'OCC. Lender's Address— I certify that I have read this application and slate that the PERMIT FEE 25 .00 • above Information is Correct. I agree to comply with all(Aunty ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25 .00 upon the ahove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE XX 7 XX Si!•nalnr�� nl I'rrm illrl -- fat