HomeMy Public PortalAbout9653 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 876(2-80) MISCELLANEOUS APPLICATION
't hereby affirm that I have a certificate of consent to self COUNTY ®F LOS ANGELES BUILDING AND SAFE'T'Y DIVISION
insure, or a certificate of Workers'Compensation Insurance,or ,
a certified copy thereof(Sec.3800,Lab.C.) f
Policy No. Company ; FOR APPLICANTTO FILL IN AUILDING
DDRESS (jtS ,�,
❑ Certified copy is hereby furnished. BUILDING + ) O� Di-. LOCALITY :r
ADDRESS 1
❑ Certified copy is filed with the county building inspection �/ NEAREST
department. /� LOCALITY T Q • cROSs ST.
Date Applicant NEAREST 4 DISTRICT-JJJ���1110. G TYPE PR SSED BY
' CROSS ST. '�'� an , _� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' i LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAPOaZ�/( HIGHWAY
NO. (CIRCLE) STATE MAJOR SECON LOCAL
I NO. OF BLDGS.
(This section.need not be completed if the work. involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS fJ
by the permit is for one hundred dollars ($100) or less.) 4'
i USE OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. V p
permit is issued, I shall not employ any person in any manner A OWNER V I(C—N IWiCH rf4l �_ J
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP 0
)K MAIL
ADDRESSLn L
CLI
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY +✓ No OCCUPANT 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 p y with such p[OVISIODS Or this permit shall be I TRAILER USE GEOLOGY INSPECTION No Spec. Knowl. ❑
deemed revoked. 1Panic Devices E:1LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter I SAFETY.PERMIT I--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 .� PARKING.
effect' SPACES REQ'D PROVIDED
License Number Lic.'Class
LIMITED TIME USE
Contractor Date O AT E DATE
❑ i FROM: TO:
I am exempt from the licensing requirements-as 1 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 i SIGNATURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date T
NO. OF EXISTING BUILDINGS `
HOME OWNER-BUILDER DECLARATION ON LOT AND USE
I hereby affirm that.- I am exempt from the Contractor's I 11 2 6 A
License Law for the following reason (Section.703 1.5, Busi-
ness and Professions Code): No. PARKING {j o O'.O 8
Q
0
' SPACES PROVIDED i# �/',/
❑ I, as owner of the property, will do the work and the
0 0 010 0 0 o z
structure is not intended or offered for sale (Section I
7044,Business and Professions Code).
PROPOSED USE OF BUILDING I 217-84
CONSTRUCTION LENDING AGENCY Smirrl_! r ;
1 hereby affirm that there is a construction lending agency i V
for the.performance of the work for which this permit is i
issued(Sec. 3097,Civ.C.).
Lender's Name I PROPOSED MAX. OCC.
Lender's Address i PERMIT FEE
I certify that I have read this application and state that the I
above information is correct.I agree to comply with all County I 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 I CE 875(2-80) G'n0 BSC E L LA 1 SII E®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 BUILDING
' z
Certified copy is hereby furnished. BUILDING 5 ` , LOCALITY
ell
ADDRESS V
❑ Certified copy is filed with the county building inspection NEAREST
department. LOCALITY /_ / ` CROSS ST. If
Date Applicant NEAREST (- G• L DISTRICT NO. GROUP TYPE PROC SED BY
CROSS ST. �/ � i` n�� CONST
CERTIFICATE OF EXEMPTION,FROM WORKERS' LEGAL .y`/ 1 V /�
COMPENSATION INSURANCE DESCRIPTION LOT NO. 3u eLocK MAP ��hn 07 NIGNWSECOND LO
AY `
NO, ap (CIRCLE) STATE MAJOR SCAL r
/ NO. OF BLDGS. ll
(This section need not be.completed if the work involved TRACT F' NOW ON LOT USE ZONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars'(5100) or less.) USE OF /l U
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this cccc
permit is issued, I shall not employ any person in any manner OWNER13 T C 09
so as to become subject-to the Workers' Compensation Laws. MAIL EV �� ti OCCUPANCY GROUP
ADDRESS
LU
Date Applicant / Cl)
NOTICE TO APPLICANT: If, after making this Certificate of CITY r4 P6 F eir' NO. AS,7-a0 a 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
deemedNo Spec. KnOWI.•❑
deemed revoked. Panic DBVICeS ❑
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
effect. I PARICO PROVIDED
SPACES
D
- SPACESS Rr%Q D
License Number Lic.Class
LIMITED TIME USE
Contractor Date DATE DATE
❑ FROIM: TO:
I am exempt from.the licensing requirements as I am a.
licensed architect or a registered professional engineer 'slzE of NO. OF I INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- ;EXISTING BLDG. P �0 a STORIES SIGNATURE
iness and Professions Code). PRESENT USE OF BUILDINGFINAL APPROVAL
Q ..
Lic.or Reg.No. DateAz 0
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE I •
r
I hereby affirm that, I am exempt from.the Contractor's
License Law for the follbwing reason (Section 7031.5•, Busi-
ness and Professions Code): NO. PARKING n �r 2 7 -7i
PROViD ED /� �,
t,
❑ I, as owner of the property, will do the work and the SPACES
structure is not intended or offered for sale (Section 1 .0 0 0 a a �,
7044, BUSInBSS and PI'OfeSS10D5 Code). PROPOSED USE OF BUILDING ..l�.y ., r O O D C O �2
CONSTRUCTION LENDING AGENCY X11
I hereby affirm that there is a construction lending agency s • Lt-p-S 1 20 1 —811
for the performance of the work for which %this permit is `
issued(Sec.3097,Civ.C.). I `
Lender's Name 1 PROPOSED MAX. OCC.
ender's Address ;ERMIT FEE ' C1
P
certify that 1 have read this application and state that the
bove information is correct;I agree to comply with all County ISSUANCE FEE
rdinances and State laws relating to building construction, TOTAL FEE �+
nd hereby authorize representatives of this County to enter ;•.7 r a
the above-me Toned pro rty for inspection purposes. ii SEE REVERSE FOR EXPLANATORY LANGUAGE
;,igna re of Permittee. Date j
WORKERS'COMPENSATION DECLARATION CE 876(2-801 MISCELLANEOUS iA PP'L(CAT 10 N
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.)
DING /
Policy No. B
Company FOR APPLICANT TO FILL IN pU. REBS
❑ Certified copy is hereby furnished. d#1-BUILDING. -LOCALITY
ADDR*SS:, IrJ
Certified copy is filed with the,county building inspection NEAREST
department. LOCALITY�-P , n CROSS ST.
•Date Applicant NEAR,6ST -C C DISTRICT NO. GROUP TYPE PROC SED BY.
"CR OSS•ST. •LV j ' CONST_. '
' CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
DESCRIPTION LOT NO. BLOCK Ap, MIGMwAv }
COMPENSATION INSURANCE Nry,O.• (CIRCLE) STATE MAJOR SECOND•LOCAL Il
NO. OF LOGS.
(This section need not be completed if the work involved TRACT NOW ON LOQ 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 '�./ Q
permit is issued, I.shall not employ any person in any manner OWNER h
so as to become subject to the Workers'Compensation Laws. MAIL Q (OCCUPANCY GROUP r
ADDRESS �• Q`5 I '•�. CL
Date ' Applicant l
NOTICE TO APPLICANT: If, after making this Certificate of clrY 1� nrio� —aha(� OCCUPANT LOAD �
Exemption, you,should become subject to the Workers' IsAPPLICA. ION.FOR EXIT HARDWARE:
Compensation provisions of the Labor Codes you must-forth-
with comply with Such provisions or this. permit shall be TRAILER•USE'[j ' GEOLOGY INSPECTIONa No,Spec. KnOM. ❑ ,
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT I-I • (LIST ITEMS BELOW) NO. OF EXITS
9.(commencing with Section 7000)of Division 3 of-the Bpsi-
ness and Professions Code, and my license is in full force-and PAR ING
effect.,• SPACIEs REq'D O PROVIDED D •-
Licensg Number Lic.Class
LIMITED'TIME.•USE '
Cont r jCtor. Date ` I DATE 'DATE
❑ ' s FROM: TO:
a ..
I am exempt from the licensing-tequirements as I am
licensed architect' Or a registered professional engineer SIZE OF' NO, OF - INSPECToa•S
acting in my professional capacity (Section 7051, Biis- EXISTING.BLDG. STORIES I SIGNATURE "
mess and Professions Code). FIN4L APPROVAL
R ESE NT'USE OF BUILD"ING / ��' ✓Fr`..�
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that-I am exempt fromthe Contractors
, ' '
License Law for the following.reason (Section '7031.5, B'usi- } # o
ness and Professions Code): NO. PARKING
SPACES PROVIDED y
❑ I, as owner of the property, will do the work and the D o O D`D a .D,�
structure is not intended or offered' for sale (Section .1. 1.22782
7044,Business and Professions Code). I
OPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby- affirm that there is a construction lending agency' On-Q. l `b-V \l V e— `
for the performanceof the work for which this permit-is I
issued(Sec. 3097,Civ.C.). I ;
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 I
ordinances and State laws relating-to building construction, (TOTAL FEE
and hereby authorize representative's of this County to enter
upo t e ab e-mentioned operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sighture of Permittee Date j
WORKERS'COMPENSATION DECLARATION 76M444 I '
CE 875 (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
Ll
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
El Certified copy is hereby furnished. UILDING
I A DRESS 9651 1/2 Las Tunas Drive LOCALITY
❑ Certified copy is filed with the county building inspection NEAREST
department. I LOCALITY CROSS ST.
Date ApplicantNEAREST DISTRI NO.` GR UP TYPE PROC E BY
CROSS ST. aZ CO NSTY�1
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALI.
COMPENSATION INSURANCE i DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
'NO. (CIRCLE) STATE MAJOR SECOND LOCAL CL
(This section need not be com P leted if the work involved TRACT NO. OF NOW ON SLOT CL
L T USE ZONE SPECIAL CONDITIONS
I - �}
by the permit is for one hundred dollars ($100) or fess.) usE of
SIZE OF•LOT EXISTING BLDG.
I certify that in the performance of the work'for which this
permit is issued, I shall not employ any person in any manner. I IVN ER Brent Cannon O
so as to become subject to the Workers' Compensation Laws. i AIL OCCUPANCY GROUPail CJ
DRESS P. O. BOX 12 i ,L
Date Applicant to
NOTICE TO APPLICANT: If, after making this Certificate of TYTem le City 917861.`.' 287-2020 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 p ovisions or this permit shall be I TRAILER USE GEOLOGY INSPECTION
deemed revoked. ❑ ❑ No Spec. Knowl.' ❑
OCCUPANCY INSPECTION ❑
TION
LICENSED CONTRACTORS DECLARATION 11 Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) I 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 i
effete'. PARKING
.` SPACES REQ'D O PROVIDED
License Number Lic.Class
. � LIMITED TIME USE
Continctor Date I I DATE OAT E
FROM: ` TO:
F1I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer I SIZE OF NO. OF INSPECTOR'S
acting in my professional Capacity (Section 7051, Bus- EXISTING BLDG. STORIES i SIGNATURE
iness and Professions Code). FINAL APPROVAL
RESENT SE OF BUILDING U
Lic.or Reg.No. Date I (f =
Vacant
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 0 0 o e 8
ON LOT AND USE -
i
I hereby affirm that- I am exempt from the Contractor's o 0 0 0 0 0 o z
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING O' 1 1 s
�
I, as owner of the property, will do the work and the SPACES•P ROVID ED
structure is not intended or offered for sale (Section
7044,Business and Professions Code). I RO.POSED USE OF BUILDING
{
CONSTRUCTION LENDING AGENCY i Sales Office
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 I PROPOSED MAX. OCG. 3
Lender's Address i
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
09 t above-me nj�'°ne property for inspecti n pu poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Da
WORKERS'COMPENSATION DECLARATION. I CE 875(2-80) W S C E L LA N E O U SI' APPLICATION
I hereby affirm that I have certificate of consent tself COUN'T'Y OF LOS ANGELES BUILDING AND SAFE'T'Y DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or i EJ
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING.
ADDRESS
❑ Certified copy is hereby furnished. ipe BUILDING LOCALITY
ADDRESS �
❑ Certified copy is filed with the county building inspection NEAREST
department. LOCALITY Y CROSS ST.
Date Applicant EAREST k-14DISTRICT NO. RO T R E ED BY
CROSS ST. I ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL }
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MA HIGHWAY STATE MAJOR SECOND LOCAL (L
NO. OE'F BLOGS. No.l (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT USZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars (5100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this I O
permit is issued, I shall not employ any person in any manner OWNERS ! I i—
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP W
• ADDRESS d
Date Applicant to
TEL. Z
NOTICE TO APPLICANT: If, after making this Certificate of Iry NO. OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth- I
wlth comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION i No Spec. Knowl. ❑
deemed revoked.
OCCUPANCY INSPECTION I Panic Devices
LICENSED CONTRACTORS DECLARATION ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT V (LIST ITEMS BELOW) NO. OF EXITS ❑
9 (commencing with Section 7000)of Division 3 of the Busi-
net's and Professions Code, and my license is in full force and PARKING
effect. SPAFES • REq'D O PROVIDED O
License Number Lic.Class
11 1 LIMITED TIME USE
Contractor Date I DATE DATE
❑ I am exempt from the licensing requirements as I am a F RDIM: TO:
licensed architect or a registered professional engineer SIZE OF No. OF I INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTIG BLDG. STORIES SIGNATURE
N
iness and Professions Code). .! FINAL APPROVAL
JWKSENT USE OF BUILDING i
Lic.or Reg.No. Date
NO.OF EXISTING BUILDINGS
HOME OWNER-BUILDER DECLARATION
ON LOT AND USE
� R.?,5A.
I hereby affirm that,I am exempt from the Contractor's I
License Law for the following reason (Section 7031.5, Busi- D o ` i'
ness 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 (SectionCI-
7044,Business and Professions Code.). o orosED 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,
and hereby authorize representatives of this County to enter T6TAL FEE i
upon the above-mentione_d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
f
Signature of Permittee Date IF
I
{' I WORKERS'COMPENSATION DECLARATION 7SM444DPw:2/90 MISCELLANEOUS APPLICATION
I hereby affirm that I have.a certificate bf consent; to self COUNTY OF LOS ANGELES BUILDING:AND SAFETY DIVISION
jinsure,or a certificate of:Wdrkers'Compensation Insurance,or
'a certified copy thereof(See 3800,Lah C.) "< "
i Poli No Company FOR APPLICANT TO FILL IN BUILDING •
i- BUILDING ADDRESS ADDRESS
I ❑ Certified copy,is hereby:furnished. $ 3 • I; us ct LOCALITY "
❑ Certified copy is filed with the county building inspection CITY' ZIP
' department. Te m 2 CA NEAREST
F1 CROSS ST. '
Date Applicant i SIZE OF LOT NO.OF BCDGS.NO N LOT DISTRICT NO. GROUP TYPE PROCESSED BY fr
coNBT.
CERTIFICATE OF-EXEMPTION FROM WORKERS'
(' I COMPENSATION INSURANCE TRACT BLOCK LOT NO.
MAP - HIGHWAY
• - ) No. (elncl.el STATE MAJOR SECOND LOCAL..
(This Section need not be completed if the work iRVOlved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
I "' TEL NO. C
f I.certify that in the performance.of the work for which this {�
permit is issued:I'shall not employ any person in any manner �10 _ D
so as to become subject to the Workers' Compensation Laws. ADOM `oA 6 t'' •�t� OCCUPANCY GROUP v
fj7 1/ / a
Date Applicant CITY 1 �� r ZIP may/
NOTICE TO APPLICANT: If; after making this Certificate ( Y i OCCUPANT LOAD
of Exemption, you should become subject to the Workers' APPLICATION FOR
' Compensation provisions of the.I abor Code.you must forthwith EXIT HARDWARE:
( comply with such provisions or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑
• ' revoked
LICENSED CONTRACTORS DECLARATION j OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW)
1 I 9(commencing with Section 7000)of Division 3 of the Business NO.OF EXITS
• and Professions Code,and my license is in full force and effect. ..
game 6t JEWs1ness
PARKING• REQ'DO
r7 PROVIDED
SPACES o
License Number Lic.Class �Q F R�$ ��
( I I Contractor Date LIMITED TIME USE
DATE DATE
El FROM:I am exempt from the licensing requirements as am a TO:
professional epgineer
licensed architect or a registered ,
acting in my professional capacity(Section 7051,Business SIZE OF NO.OF I INSPECTOR'S
EXI
and Professions Code). I STING BLDG. ZS`O STORIES SIGNATU F_
Lic, or Reg.No. - Date
PRESENT use of BUILDING FINAL APPROVAL 7A, 0 3
. • 4Iz ,
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
i
� 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
i El I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale(Section 7044,2 PROPOSED USE OF BUILDING
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
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.). i PROPOSED MAX.OCG
Lender's Name APP CANT(PAINT) TEL NO.
I C3Mllda t-fN Cq(-A) -CNAfJ .
Lender's Address ADDRESS
1 , I certify that I have read this application and state that the 5 C i- c4
above information is correct. I agree to comply with all County PERMIT FEE
ordinances and State laws ielating to building construction,and
hereby authorize representatives.of this Coady to enter upon ISSUANCE FEE
wr- the above-mentioned property for inspection purposes. -
f'
r TOTAL FEE .'
% oC.Gy, �ih0.� ✓kT /a', sao 3 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of ermittee Datd
WORKERS'CU:v1P$NSACIUN DECLARAIIUN 16M444 M ISCELLANEOUS A PLICATION
CE 875(11-84) ..
I hereby o a cert that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
inset;:, 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
FiCertified copy hereby X
PJ
❑ is hb furnished. BLOCALITY
UILDING df3 C
`
ADDRESS
C artiend copy is filed with the county building inspecti �1 LOCALITY NEAR EST
p \ CROSS ST.
Date Applicant NEAREST DISTRICT NO TYPE P ESSED BY
CROSS ST. a(� h„�yL O / GR P CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP I MIGMWAT STATE MAJOR SECOND LOCAL
NO. ! (CIRCLE)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT K
CIAL CONDITIONS
by the permit is for one hundred dollars (5100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any mariner OWNERso as to become subject to the Workers' Compensation Laws. rnn�L CY GROUP o
Date Applicant gDDREss OS r� a elf ff
r
TEL, OCCUPANT LOAD
NOTICE TO APPLICANT: If,after making this Certificate o� 1CITY ��'o No. 616—y��-6�{L j
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 i TRAILER USE El GEOLOGY INSPECTION E] No Spec. Knowl.
deemed revoked. I Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$$
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 0 (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- 1 NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKINGi REq'D PROVIDED
GG(� SPACES
License Number Lic. Class 1 LIMITED TIME USE
Contractor .Date DATE DATE
FROM: O:
1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
EXISTING BLDG. STORIES SIGNATURE
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
!� /�_/♦n
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Ree.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE U 1
I hereby affirm that I am exempt from the Contractor's i v
License Law for the followine reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
I N
I, as owner of lite property, «•ill do the work and the SPACES PROVIDED
,a
structure is not intended or offered for sale (Section. 1
7044,Business and Professions Code).
CV'
X"''!PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY .\--II pK S �y4
I hereby affirm that there is a construction lending asericy e-o � _
for the performance of the work for which this permit is I+ p
issued(Sec. 3097,Civ.Q. �
Lender's Name
PROPOSED MAX.OCC.
Lender's Address Ir
I certify that I have read .is application and state that the
PERMIT FEE 25.UU
�§
above information is correc.1 agree to comply with all County ISSUANCE FEE }
ordinances and State late relating to building construction, M
and hereby authorize rep sentatives of this County to enter TOTAL FEE 25.00.
u o>Z the above- entio ropert} for inspection purposes. ;
'V 1\ j _(� �q� SEE REVERSE FOR EXPLANATORY'LANGUAGE
,I 1
` Signatu r. ttee Date
WORKERS' C'OMI'ENSAfION DE('L.ARAI'ION ' 'L,M•I.1.1 MISCELLANEOUS APPLICATION
1 1 hereby affirm that I have a certificate of consent io sell't COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Il
'insure,or a certificate of Workers'Compensation Insurance.or
a certified copy thereof(Sec.3800. Lib.C.)
Policy No. , Company ) FOR APPLICANT TO FILL IN BUILDING
I BUILDING ADDRESS PDDRESS
❑
Certified copy is hereby furnished.
\ J �� { TIm I, �' IpOCALITY
❑ Certified copy is filed with the county building inspection CITY ` ZIP NEAREST
_) department. 0 CROSS ST.
Date..___ Applicant SIZE OF LOT NO.OF BLDG .NOW ON LOT DISTRI T NO GRO P TYPE ESSED BY
CONST.
C'ERTIFICAH: OF EXEMPTION FROM WORKLRS' I -- D; /� �
TRACT BLOCK LOT NO.
C-OMPENSAHON INSURANCE I NO. GI RCLEI STATE MAJOR SECOND LOCAL `
(This section need not be Completed if till` %%ork intuit'e'd ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS r"
by the permit is for one hundred dollars 1~100) or Icss.)I (`
OWNERTEL NO.
�1 I 1 certil'y that in the perR)rinance I)[* the work Ga• which this- �� I`LL-
I permit is issued. I shall not employ any person in Nati• manner AD ® n.
so as to become subject to the Workers' C'rnnpce
ensation Las. ADDRESS c"� � OCCUPANCY GROUP t'•
Date Applicant CITY
- NOTICE TO APPLICANT: 11', alter making this Certificale _ OCCUPANT LOAD
of Exemption. you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code.you must forthwith
comply with Such provisions lir this permit shall he deemed TRAILER USE❑ GEOLOGY ❑
I I Y INSPECTION i No Spec.Knowl. ❑
revoked. ❑
1 OCCUPANCY INSPECTIONS Panic Devices
LICENSED CONTRACTORS DECLARATION 1
1 hereby affirm that I am licensed under provisions llf (llilf)lerl SAFETY PERMIT❑ ILIST ITEMS BELOW)
y J 9(commencing with Section 7000)of Division 3 of the Business. NO.OF EXITS
s I and Professions Code.and my license is in full lI)=and effeed —
SPACE�ARKIG• REQ'D D PROVIDED
ggeZV
License Number Lic.Class SPACES
I Contractor Date -- —d — -- ---- -- —— LIMITED TIME USE
DATE DATE
❑ 1 alit exempt from the licensing requirements as I am iI, FROM: TO:
licensed architect or a registered professional engineer
'
acting in Illy professional capacii5•(Section 7011, IIIISIIIeS) SIZE OF NO.OF INSPECTOR'S
and Professions Code). , EXIS rING BL.UG. —_— SiORIC.S ATURE
SI
Lic.or Reg. Na Date PRESENT USE OF BUILDING Cie- 5, � FINA�LJ APPROVAL
'-! I HOME OWNER-III IIL.DER DFULARAI ION NO.OF FXIsrING BUILDINGS _- - _—.•--- �V J
UN LOT AND USE
hereby affirm that I am exempt front the C'ontractor's license
Law for the following reason (Section 70315. Business and n flol
Professions Code): i NO.PARKING V ►1
SPACES PROVIDED I I
❑ I. as owner of the propert. will do the %%ork and the! — — ------ �. ,�►
structure is not intended or offered Gn sale(5eclion 704411 PROPOSED USE OF BUILDING
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency IMI
the performance of the work for which this permit is issued,
• I i (Sec.3097,Civ.C.). PROPOSED MAX.OCC.
` I
Lender's Name ____ ...._..._ _. ... I APPLICANT 1PRONTI TEL NO. I
XA AA
Lender's Address I ADDRESS
I certify that I have read this application and state that thl; 19itll D, o%-- SW )t' vl>: 4
above information is correct. I agree to C0111ply with all County( ET FEE
;
I ordinances and State laws relating to building construction.and PERMIT
hereby authorize representatives of this County to entCr LIp011I ISSUANCE FEE 4
the above-mentioned property for inspection purposes. !
vl.
0 I � TOTAL FEE
SGIi REVERSE FOR EXPLANATORY LANGUAGE"
Iar— ature� r ' tee Date i
L
►_. WORKERS*COMPENSATION DE('L.tItAT10NI CE 875:11-841 MISCELLANEOU APPLICATION
� CE 87.�i
1 hereby affirm that I have a certificate c,f 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.1. - `r
Policy No. _C ontrany ) FOR
APPLICANT TO FILL IN a I ess ' Vw
Certified copy is hereby furnished. ABUILDDRESS q 5J Las T� ws Dr-ox LioAI,Irr
1 ' ❑ Certified copy is filed with the count%.building inspection Ix LOCALITY Temple Cit NEAREST
department. i P y CROSS ST.
( Date .applicant NEAREST 'IST T N}} . G UP TYPE CESSED BY
CROSS ST. • y CDN
I CERTIFICATE OF EXEMPTION FRO\l'.t'QRI:E•RS' LEGAL O
L OMPENSATION INSUR.%NCIE ) DESCPIPT:ON LOT NO. BLOCK 1 MAV .1G1+w wT
N�. ICIRCLEI STATE MAJOR SECOND LOCAL
I NO. OF BLDGS.
(This section need not he completed if the work Involved I 1-RAC7 NOW ON LOT U�E ?ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (SI00) or less.) ?
USE DF f
t SIZE OF LOT EXISTING BLDG.
I certify that in the verformance ,f -he work. :o:which -Itis
permit is issued. I shall not m'employ anercon in any manner OWNER
so as to become cuhieet :o the Workers* 17,ma^ensatior. l.aa't � 1 4 AIL
OCCUP4NC` GROUP
ADDRESS
Date :applicant �f� _
NOTICE TO APPLICANT: If.af-.er makinL :iris :-c-t;+icarr :; $I c:r• •�'�AVLV ) C�+r Nc �up�Z�..Ip'`i3 ` r'CCUP^•N-L Jac
Exemptia•t. you ;itould become aui+iec: -he Worke _
compensation amrisions of:he Labl�r t'auL. }you trust torth-
with comaiv with <uch ^rovis:on< iii: ••er•nit ;hail he -PAILEP USE GEOLOGY :NSP_CTICN No SCeC. •.<:lCtii. L!
deemed:e:nked.
K j OCCUPANCY INSPECIONS Panic Oe
! `/'Ces
- LICENSED CONTRACTORS DECLARATION T1 ❑ I
I hereby affirm :hat Iam licensed under provisions of C;iaapte: + SAFETY PERMIT ` M
'LIST ITEMS BELOW)
9 (comntencine with Section 0001 of Division )t the Busi- I ND. OF ..ITS I
ness and Pccafeasions Code.and my license i$ in roil force andL�
eifec:. P RxING f—
SPiA CES REO•D I PRCVID
1 License \unaber_ Lic. Cla:; ' LIMITED TIME USE
LL
'n Contractor- __ !)aie i DATE DATE
V+ __--
W
Z l rnFy: TO:
❑ I am exempt frorn the Neensing reauirementc as I am a
I I INSPECTOR S
m I llrense1l :arC111iCC: Or a :e8liieied r-!tiessielral engineer SIZE OF NO. O� SI TORE
z actin^ :n m' prcieuir.oral .. a_it i1„ -ncl. fi ll i- EXISTING BLDG. -OP. ES
inesiandi'-UfessicmLodeI. FINAL APPROVAL -�—
U ' ^RESENT USE OF BUILDING
Lic.or Re=. No. __ D.ate----
LJ
HOME Oat'Ni R-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �/
' ON LOT AND USE I1
I hereby affirm that I :Int exempt from the Contractor',;
License Law for the folloviar_ reason 'Section -031.4. Buci-
ness and ProiessionsCode): NO. PARKING
SPACES PROVIDED
❑ 1• as owner of the property. will do the ,work and the I
structure is not intended or offered for cele (Section
1 7044.Rusinect and Professions Codd.
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending ageney ' g�
I for the performance of work ork for which this permit is f• T X if 0.
issued(Sec. 309 7.Civ.C.). y�q
Lender's Name f
' PROPOSED MAX. OCC. t
Lender's.address
1 1 CCrt9f\' tR3l 1 have read this application and state that the PERMIT FEE 25.�� k�'
above infonnatitrn is correct.I agree to comply with all County ISSUANCE FEE
f ordina 'es :and Sta a laws relating to building construction.
and h by autho. a epresentatives of this County to enter 1 TOTAL FEE 25.00
t 1 I upon t L above-roe 'o d property for inspection purposes. I SEL REVERSE FOR EXPLANATORY LANGUAGE I151.
Sienature of Permittee Oate
r
WORKERS'CObi['ENSATION DECLARATION 4
CE 875 r11-841 f 'I SC E L LA N EO;U S APPLICATION
CE 87
I BUILDING AND SAFETY DIVISION o affirm that 1 have a certificate of consent r)o self COUNTY OF LOS ANGELES l
- insure,ure. or a certificate of Workers'Compensation Insunirlce,or
�I__ ILDING
J a certified copy,thereof(Sec.3800.Lab.C.). .
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS /QLtJA.2
f ahas p r`Q ,
Certified copy is hereby furnished. il BUILDINGry 3 �U D i LOCALITY
AD OR ES57 Cit
s
1 Certified copy is tiled withwiththe county building insp�ctlon LOCALITY Temple NEAREST
department. P y CROSS ST.
Date Applicant NEAREST �I/G� DISTRICT NO. GR UP TYPE ESSED BY
CROSS ST. // CONS
CERTIFICATE OF EXEMPTION FROM WORKERS* LEGAL a
I COMPENSATION INSURANCE I Or S CRIPTION LOT NO. I9L0 CK !MAP HIGHWAY
' I
O. OF BLDGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL
N
(This section need not be completed If the work inbolved TRACT NOW ON LOT I USE LONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (5100) oil less.) I USE OF
ISIZE OF LOT EXISTING BLDG.
I certify that in the performance of :he\\•ork for .vIiidh this
P&OPM.Ey
permit is issued. I shall not emplo} any person in any manner OWNER ID
so as to become suliect to the Workers' Compensation-Laws. OCCUPANCY GROUP
MAIL �oS ;& Y'C_ r 6 a'
I
ADDRESS
I Date — Applicant _
NOTICE' TO APPLICANT: If,After making this Certificate -it $I CITY b a, G u'W- 7_R —� � OCCUPANT LOAC
Exemption. you should become subject to the Wnrkers' 4POLICATION FDR 1 EXIT LIARDWARE'
Compensation provisions of the Labor Code. you mustiforth-
Wltll COmpl\• \4'Itil iUCl1 p[O\'15iOnti or e111G ermir sljall be TRAILaR USE I,] GEOLOGY INSPECTION _ NO Soec. Kt1OUVl, ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$$ i Panic Devices
I hereby affirm that I am licensed under provisions of Chaoter n
9 tcommencine with Section 0001 of Division 3 At the Busy SAFETY PERMIT LJ (LIST ITEMS BELOW) NO. OF EXITS
ness and Professions Code,and my license is in full force and ��effect. PARKING
S"CES REO'O 1 I 'PROVID EO
License Number Lic. Class lI. LL--JJ
! LIMITED TIME USE
w Contractor Date DATE DATE
W
Z R•iOM: TO:
N 0 I am exempt from the licensing requirements :is am .1
m M licensed architect or a registered professional engineer ;IZE of NO. OF INSPECTOR'S
Z acting :n :n}• professional :aracit,- Holl -Il�I, BII C- EXISTING BLDG. STORIES i
SIGNATURE
a iness and I'rotessicns Code i. FINAL APPROVAL
U PRESENT USE OF BUILDING '
U Lic.or Rea.No. Date CS
!
HOME OWNER-BUILDER DECLAR.k1'ION NO. OF EXISTING BUILDINGS lr7
ON LOT AND USE 6, 0
I hereby affirm that I am exempt from the Contractor'% —
( License Law for the following reason (Section 7031.5. Busi
ness and Professions Code): NO. PARKING /
1, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section �
1 704.1.Business-and Professions Code).
i g
CONSTRUCTION LENDING AGENCY
PROPOSED USE OF BUILDING c(4
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.). i I
Lender's Name I t
PROPOSED MAX. OCC.
Lender's Address !
I ) 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 Courity ISSUANCE FEE
ordinances and State laws relating to building construction,
and her authorize representatives of this County to enter TOTAL FEE 25,00 I 3 C:.1
! upon 1 :i ove ntione property for inspection purposes.
I SEE REVERSE FOR EXPLANATORY LANGUAGE IQ
�f
3- 1
I/\ Sign.t re of Permitte Date
l I WORKERS' UUMMCIVJA1tUNUCI.LAKA11V1V 20-0063DPW72/90 IVII�t__til L_LHINr.V1.1,> Hr'rL.II,.HI IUIN
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 (Set.3800, Lab.C.) `
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
BUI DI AQqDRESS y ADDRESS
Certified copy.is hereby:furnished. X ��jj LOCALITY
Certified copy is filed with the county building inspection CITY ZIP cy/ n
t department 7e Y1v l e G 1T ! 1 /� CROSS sr.
Date - + Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE I PROCESSED BY C
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO, CONST. `
( I COMPENSATION INSURANCE MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL.
(This Section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
t I certifythat in the performance,of the work for which this T
b TEL NO.
permit is issued.I shall not employ any person in any manner O C to U
so as to become subject to the Workers' Compensation Laws. OREss OCCUPANCY GROUP tJ
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❑
1• No Spec.Knowl.
revoked. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION C% Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) a
t I 9(commencing with Section 7000)of Division 3 of the Business Name o us ness NO.OF EXITS
and Professions Code.and my license is in full force and effect.11
PARKING• REO'D O PROVIDED D
License Number Lic. Class ,p res S . sPAces •
( I Contractor Date _ LIMITED TIME USE
❑ I am exempt from the licensing requirements as I am aDATE DATE
licensed architect or a registered professional engineer FROM: TO:
( acting in my professional capacity (Section 7051,Business SIZE GING BLDG. SNO.OFTORIES SPECTOR
INSIGNATURE.
and Professions Code).
Lic. or Reg. No. Date PRESENT USE OF BUILDING FINAL APPROVAL OZ _
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
I 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
l 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 7044,1 PROPOSED USE OF BUILDING
Business and Professions Code).
t O -a..L-..
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.). PROPOSED MAX.OCC.
j Lender's Name APPLIC T(PRINT) I TEL NO.
Lender's Address ADDRESS
( iI 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
I hereby authorize representatives of this County to enter upon ISSUANCE FEE
the above-yaerttioned property for inspection purposes.
.. I TOTAL FEE - - -
% SEE REVERSE FOR EXPLANATORY LANGUAGE
Signof Permittee ate