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Home My Public Portal About9636 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 8754It (2 80) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self inc,,re, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN But NG ADDRESS •t,J p �(� y ❑ Certified copy is hereby furnished. BUILDING !f /_ /1� O 7 lA/`M A� LOCALITY ADDRESS 7CFJ �J /•'�{�' �V/v .V G ❑ Certified copy is filed with the county building inspection „�/ /7! �}7 NEAREST department. LocwLlrr � IrrP�y l 5 iIJC 0 cRoss sr. Date Applicant NEAREST DISTRICT No. [:;LUPTYPE PRO SSED B CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL -4-! COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOAp ®d HIGHWAY }(CIRCLE) STATE MAJOR SECOND LOCAL 11 NO. DO BLDGS. USE ZONE SPECIAL CONDITIONS Q (This section need not be completed if the work involved TRACT Now oN Lor U by the permit is for one hundred dollars (5100) or less.) usE OF SIZE OF LOT EXISTING BLDG. C�7 tx I certify that in the performance of the work for which this t Q permit is issued, I shall not employ any person in any manner OWNER hAr- so as to become subject to the Workers' Compensation Laws. MAIL n OCCUPANCY GROUP /Sty?� W ADDRESS lB b 44-S s,t� Date Applicant TEL. �►- Q r' NOTICE TO APPLICANT: If, after making this Certificate of CITY'T NOL J$ 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. OCCUPANCY INSPECTION Panic Devices LICENSED CONTRACTORS DECLARATION ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (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 REWD = 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- E ISTING BLDG. STORIES SIGNATURE iness and Professions Code). N I r FINAL APPROVAL t- — 7� ESENT USE OF BUILDING 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 !O 1 2 NO. PARKING License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): SPACES PROVIDED D D a o ❑ I, as owner of the property, will do the work and the , structure is not intended or offered for sale (Section o a o D a D D 7044, Business and Professions Code). RO POSED USE OF BUILDING �1,t. e 629-81 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance Of the work for wJiich this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCG. 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 'nanc-S and State laws relatin to building construction, ,and eree authorize represent es of this County to enter TOTAL FEE Dpo the above-men ' n r erty for ins ec u oses. SEE REVERSE FOR EXPLANATORY LANGUAGE t I nature of Permittee7 Date I t b'10RKF$S'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION 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,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. ILDING U/ �n7 // / /IJ c- " ADDRESS fP ✓ (/ s- vm i— LOCALITY Certified copy is filed with the county building inspection OCALITY -rp mM � L'I� vYI' NEAREST department. CROSS ST. V Date Applicant 01tAREST DISTRICT NO. GROUP TYPE PROC SSED qY CROSS ST. ,`^f CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAr HIGHWAY STATE MAJOR SECOND LOC NO. OF BLDGS. N0. ,16'0-07(CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPE CiAL 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 OWNER so as to become subject to the Workers' Compensation Laws. IL VQ OCCUPANCY GROUP o Date Applicant ADDRESS 3 ` s— Tu ems t. v NOTICE TO APPLICANT: If, after making this Certificate of TY�e �Q� C L NoS1S�oZ�(-��3133 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 oI 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) 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 REq'D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF FROM: To: INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 3�xa URE iness and Professions Code). Pry 5� w FINAL APPROVAL' �j s NT USE OF BUILDING rd.- / Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exemptfrom the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING - I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). 1 POSED USE OF BUILDING OrV s-1-Q�f•L CONSTRUCTION LENDING AGENCY A 5 5 Q O A I Hereby affirm that there is a construction lending agency 8 8 for the performance of the work for which this permit is Q. \ . 0 0 0 0 issued(Sec. 3097,Civ. . /y1,' 0 0 0 0 0 0 o z Lender's Name {rj PROPOSED MAX. OCC. ::JJ , 0 9.2 5—OO 6 Lender's Address 7 G I certify that I have read this application and state that the ffPERMITabove information is correct.I agree to comply with all County EEordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter Z;;�Z; yOo.nedr�opeypor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date I • " • i WORKERS'COMPENSATION DECLARATION I' 76M444 M-I SC E L LA N EO USS APPLICATION ' i CE 875(2.80)-,.• - I hereby affirm that I haute.'a certificate of consent to self "BOUNTY OF LOS ANGELES` BUILDING AND SAFETY DIVISION 1 insure, or a certificate of Workers'Compensation Insurance,or I i a certified copy thereof(Sec.•3800,,Lab.C:) 1 � 1 Policy No. Company, FOR APPLICANTTO FILL INEl iBU1LDINGOf (ADO Rfi SS Certified co Is hereby furnished. BUILDINGZf 'FAA ��s. 7-411VK.r- IL y}-- Py y LOCALITY- (,,�,sG ADDRESS Certified copy is filed,with the county building inspection I NEAREST department. LOCALITY jcRoss sr. Date ApplicantEAREST n/� DISTRIG NQ./ �GROOP TYPE `_ prtESSED BY CROSS ST. C�7 (a LLQ • V�•• UJ.Y/Cl/ CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK I.MAP HIGHWAY }- I' , 'Ho. (cIRc6E) STATF MAJOR SECOND LOCAL C I NO. OF'BL CONDITIONS (This section need not•be_completed if the work involved TRACT NOWON LOTT 'USE ZONEF�1..AL - by the permit is for one hundred dollars ($100) or less.) j U , USE OF SIZE OF LOT EXISTING BLDG. .21 13C I certify that in the performance of the work for which this O permit is issued, I.shall'no.t employ,any,person in any manner NSR XII-41 X 16-fel'0 ID ORS I F- -so •so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP U oMAILADDRESS 9KJ0 Z/V '1UA1W_f AV. I 0"'. Date Applicant I`. �J p p G7 NOTICE TO APPLICANT: If, after making this Certificate of, Ctrv' T. C', NOI Ped �'�f�J i OCCUPANT LOAD ' Exbmption, you should become subject to the Workers" I Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:I with comply :with Such provisions or this permit shall be�, TRAILER USE GEOLOGY INSPECTION deemed revoked. ❑. I No Spec. Knowl. ❑ (: /� G Panic Devices ❑ LICENSED CONTRACTORS DECLARATION., OCCUPANCY INSPECTION „� --9 TI � I hereby affirm that I am licensed under provisions of Chapte SAFETY PERMIT q (LIST-ITEMS BELOW) I NO. OF EXITS 9 (commencing with Section 7000) of Division'3 of the Busi ne'ss and Professions Code, and my license is in full force an effect. SPACES REQ'D O PROVIDED ARKING. L jense Number Lic.Class I LIMITED TIME USE Contractor Date i, DATE DATE • (FROM: TO: I am exempt from the licensing requirements as I am ij INSPECTOR'S licensed architect or a registered professional engineer SIZE OF NO.•OF i, SIGNATURE acting in my professional capacity (Section 7051, BUSK EXISTING BLDG. STORIES iness and Professions Code). i ESENT UE OF BUILDING �F NAL APPROVAL Lic.or Rek.No. Date I P SD �� Cd CO �/� 1 . I' NO.OF EXISTING BUILDINGS ' HOME OWNER-BUILDER DECLARATI.ON ON LOT AND USE I hereby affirm that I am exempt from the Contractor's 2 8 7 1 License'Law.for the following.reason (Section 7031.5, Busi= mess and Professions Code): I NO.PARKING _ SPACES PROVIDED 1, O O O I, as owner of the property, will do the work land the " P # 8 8 structure •is not intended or offered for sale (Section o 0 0'0 0 0 a N , 7044,Business and Professions Code). j ROPOSED USE OF BUILDING.Dp/s."c, .t70RG' Gam(/v'= iwv _ j CONSTRUCTION.LENDING AGENCY D 6 15-53 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 ISSUANCE FEE above information is correct.I agree to comply with all County Ordinances and State laws relating to building construction, TOTAL FEE ry O and hereby authorize representatives of this County to enter upon the ve- nti roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE' 7rre of Per 1 Date i WORKERS'COMPENSATION DECLARATION 76M444 CE 875(11-84) MISCELLANEOUS APPLICATION {� I lurq Jo fafcert that I have a certificate of consent to c self COUNTY OF LOS ANGELES , BUILDING AND SAFETY DIVISION LI insur or a certificate of Workers'Compensation Insurance,or a cer hied copy thereof(Sec.3800,Lab.Q. /�/� /}��/ y/�� /A/ Policy No. Company BUILDING FOR APPLICANT TO FILL IN ADDRESS b3 "* /L, FlCertified copy is hereby furnished. JAID UILDIN LOCALITY C DRESCertified copy is filed with the county building inspectionOCALITY ! C 41Z�(� MEANEST ROSS sT. ` department. Teimoe Date Applicant NEAREST DISTRICT j1 ROUP TYPE PRO SE BY CROSS ST. ^U\ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L COMPENSATION INSURANCE DESCRIPTION I LOT NO. HLO CK MAP NIGNw AY STATE MAJOR SEC44 LOCAL NO. (CIRCLE) NO. OF HLDGS. (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 OP ZE 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 OWNER s /` c— C IJ,4—) I' so as to become subject to the Workers Compen tion Laws. AIL L _ I' OCCUPANCY GROUP o Dated— fL �- ` ADDRESS 6 T 6 ((�n�qS �J. � Applicant c O/ NOTICE TO APPLICANT: If, after making this Certificate of• cITY �{�{� c1 NO� 7I6`A— Z�3 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. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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. PARKINGREQ'D PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date D ATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a re isteredprofessional engineer SIZE OF NO.OF I PE CTOR'S acting in my professional capacity (Section 7051,, Bus- EXISTING BLDG. STORIES 1GNATURE iness and Professions Code). C FINAL APPROVAL Lic.or Reg.No. Date PRESENT USE OF BUILDING AM)#,f, HOME OWNER-BUILDER DECLARATION NO. OP EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's �� 1 2 Q,9 A License Law for the following reason (Section 7031.5, Busi- # 0 0 0 0 8 8 ness and Professions Code): NO. PARKING ! I, as owner of the property, will do the work and the SPACES PROVIDED 1��` 0 0 0 0 0.0 0 Cn structure is not intended or offered for sale (Section (� 0 0.00-88 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING SI O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. 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 5 Ov u'on thea ve-mentioned p perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE v I(—2)--9f Signature o ermittee Date WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS ISCELLAAE®US APPLICATI®N I hereby affirm that I have certificate of consent self 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.C.) BUILDING Policy No. Company I FOR APPLICANT TO FILL IN A0ORESS r ❑ Certified copy is hereby furnished. ILDIN'GDRESS 963 �W//��,� -Cw n,, IV�r I LOCALITY ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. Date Applicant NEAREST DISTRICT_NO. ROUP T E PROCESSED BY CROSS ST. �� _/j�/ J CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION LOT NO, BLOCK MAP NIDNwwr '. COMPENSATION INSURANCE I NO. F BLDGS. No. (CIRCLE( STATE MAJOR SECOND LOCAL tl (This section need not be completed if the work involved � TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.) USE of y ZE OF LOT EXISTING BLDG. / �� Ir I certify that in the performance of the work for which this I V O permit is issued, I shall not employ any person in any manner WNER pts I— so as to become subject to the Workers' Compensation Laws. i MAIL Y2 OCCUPANCY GROUP W D D R ES S (t L-0-- l Lt� Dr. i'b-� C. Date Applicant rEL. z NOTICE TO APPLICANT: If, after making this Certificate of JIM C rvo. S j C�4 Z 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 C No Spec. Knowl. ❑ deemed revoked. El Panic Devices ❑ LICENSED CONTRACTORS DECLARATION occuPwrvcv INSPECTION I hereby affirm that I am licensed under provisions of Chapter i 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. i PARKING SPACES REQ'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 , slzE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus-%XISTING BLDG. STORIESSIGNATURE viness and Professions Code). RESENT USE OF BUILDING �/] hN fl FINAL APPROVAL �j_�r��j �• r ,` Lic.or Reg.No. Date i r HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE f 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 L n El 1, as owner of the property, will do n the work and the ; 7•Ir/, A structure is not intended or offered for sale (Section 4o 0 0 0 [) 7044, Business and Professions Code). PROPOSED USE of BUILDING 0 0 1 0 O O O O G CONSTRUCTION LENDING AGENCY I rr I hereby affirm that there is a construction lending agency l�v L - r 9. —82 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 II 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 i ISSUANCE FEE ordinances and State laws relating to building construction, I TOTAL FEE Kdon hereby authorize represe tatives of this County to enter I the abov en ned op y for inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE 1 I Slgnatu rmf tee WQ.RK>;RS'COMPENSATION DECLARATION CE 876(2-80) MISCELLANEOUS 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' rs'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company BUILDING FOR APPLICANT TO FILL IN ,.. ADDRESS ❑ Certified copy is hereby furnished. BUILDING F, LOCALITY ADDRESS i�- - 0 Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUPTV PE PROCESSED BY CROSS ST. �5• .CONST. ' CERTIFICATE 6F EXEMPTION FROM WORKERS' LEGAL 'STATE MAJOR SECOND LOCAL } COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY O NO. OF BLDGS. NO. (CIRCLE) U (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.) LU USE OF J - I certify that in the performance of the work for wh(ch this SIZE OF LOT EXISTING BLDG. U= 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 cc ADDRESS Date Applicant ` cc NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL. ONO. OCCUPANT LOAD JL Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- LLLJ with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION deemed revoked. ❑ Cl NO Spec. Knowl. ❑❑ LICENSED CONTRACTORS DECLARATION ►Jt OCCUPANCY INSPECTIONJR� 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 p effect. PARKING == - 9PAC E5 REO'D I I PROVIDED License Number Lic.Class Address • ��1! LIMITED TIME USE Contractor Date / DATE DATE I am exempt from the licensing requirements as I am a. PhMe 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 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 DI, as owner of the property, will do the work and the structure is not intended or offered for sale (Section ,r • • • • '..f r, 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 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 .and hereby authorize representatives of this County to enter uj�)n the aboye-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date TV%1 ML1\0 t\ T11 LI\Jf1I 1\/I1 1JL\ L:11\f111\il� 'I �n-OUb,,DPWIY 1io I &—I—/A'N�` ■�p� ��~II�'�� 111 ■LN • I !-,hergby affirm that I have a certificate of consent W self COUNTY OF LOS ANGELES V '' BUILDING AND SAFETY DIVISION insure,or a certificate of Workers'Compensation Insurance,or II a certified copy thereof (Sec. 3800. Lab.C.) Policy No._ Company FOR APPLICANT TO FILL IN BUILDING / BUILDING ADDR SS ADDRESS 2 Certified copy is hereby furnished. "Cl�' � v D LOCALITY ❑ Certified copy is filed with the count) building inapt,tion CITYZIP NEAREST -1 department. L P_U`^ @ i I d CROSS ST. Date Applicant I SIZE OF LO NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPEPROCESSED BY CONST. I C'Eltl'Il l('AI'I: OF EXEMPTIONI ROM WURKI:RS' TRACT BLOCK LOT NO. ( COMPENSATION INSURANCE NOP cncWei STATE MAJOR SECOND LOCAL L. (This section need not Ile completed if tall' work in%tllved ASSESSOR MAP BOOK PAGE PARCEL11SE ZONE SPECIAL CONDITIONS t by the permit is for otic hundred dollars 1�10O)•or lc%s.) I � 1 certify that in the performance of the work lily whichwhich [his OWNER Ali A 1 r TEL NO. ( i I permit is issued. I shall not employ any person in any manner Mid t t I so as to become subject to the Workers' Compensation Law,.. ADDRESS � � OCCUPANU tis"[ L olti CY GROUP �J i Date Applicant CITYZIP NOTICE TO APPLICANT: If. after making this C'ertific:lte �aLIACY�,1 OCCUPANT LOAD of Exemption, you should become subject to tine Workers' APPLICATION FOR Compensation provisions of the labor Code.you must forthwith EXIT HARDWARE: comply with such provisions or this permit %hall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ I i revoked. No Spec.Knowl. pp,, ❑ OCCUPANCY INSPECTIONIK Panic Devices ❑ LICENSED CONTRA("fU125 DE('l_AR:1fIUN 1 hereby affirm that I am licensed under provisions of C hilpter SAFETY PERMIT❑ ILIST ITEMS BELOW) p I 9(commencing with Section 7000)of Division 3 of the Business NO.OF EXITS d and Professions Code,and my license is in full lorce and effect. PARKING• ' SPACES REQ•D [=. T PROVIDED License Number Lie. ('lass Contractor Date S2to6_ i 0 �_ -yl C _ J I i - LIMITED TIME USE _ � I I DATE DATE" ❑ I am exempt from tile licensing requirements its I :am a FROM: TO: licensed architect or a registered professional engineer l 1SIZE OF NO.OF INSPECTOR'S acting in my pmfcssianal caparit' (Section 705 1. 1lusiness I and Prolessions Code). Lie. rING BLDG. STORIES BIGNATURE Lic.or Reg. Na_.--.- .,_ _ Date 1 PRESENT USE OF BUILDING l� FINAL APPROVAL �d p( I - - HOME OWNER-BUILDER I)ECLARAHON No.OF r xisrING BUILDINGS I ON LOT AND USE I hereby alTinn that I am e%enlpt front the Contractor's License Law for the following reason (Sectitm 7031.5, Business and Professions Code)- NO.PARKING SPACES PROVIDED ❑ 1, as owner of the properly. Bill do the stork and the --'--- structure is not intended or olTered tut sale(Seeiitlll'7044, PROPOSED USE OF BUILDING Business and Professions Code). CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agelliN for the performance of the work for which this permit is iwied I I (Sec.3097,Civ.C.). .� PROPOSED MAX.OCC. \J I Lenders Name _— .—... _ .-. APPLICANT(FR WT TEL NO. Lender's Address ADDRESS I certify that I have read this application and state that the �• f above information is correct. 1 agree to comply with all County PERMIT FEE I ordinances and State laws relating to building construction,and hereby authorize representatives of this Count' to enter upon ISSUANCE FEE i the above-mentioned property for inspection purposes. .i v TOTAL FEE t IX '�'—ZS'r�✓� SEE REVERSE FOR EXPLANATORY LANGUAGE' 4 Signature of Permittee Date I 1 i 1