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HomeMy Public PortalAbout9661 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 M I SC E L LA N EO U S APPLICATION {� IJ I here$y affirm at'I have a certificate of consent to self CE 875 (11-84)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. V ADDRESS v LOCALITY Certified copy is filed with the county building inspection / LOCALITY NEAREST department. �/ f CROSS ST. Date Applicant NEARESTDISTRICT NO, G P TYPE PRO ED BY CROSS ST. I/ CON ST�,/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY rvD. (CIRCLE) STATE MAJOR SE CO D LOCAL NO. OF BLDGS. (This section need not be completed 1 WOIK�rNOlVeTRACT NOW ON LOT USE Z S E PECIAL CONDITIONS by the permit is for one hundred tars ($10 • USE OF I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. O permit is is uI I shall not employ any person In any manner OWNER =' so as to b u a subject to Workers' Com sation Laws. MAIL OCCUPANCY GROUP _ o ADDRESS u' v V Dateqh1fApplicant l LO NOTA APPLICANT: If, after making this Certificate of CITY' ' NO� Z — OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLIC TION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be ❑ ❑ No Spec. Knowl. P Y P P TRAILER USE GEOLOGY INSPECTION 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 REgD PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: El I 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- EXISTING BLDG. STORIES SIc ATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date (/ HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS :9 6 8 3.3 A ON LOT AND USE I hereby affirm that I am exempt from the Contractor's # • • • • 3 0 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING • • • • • • • z I, as owner of the property, will do the work and the SPACES PROVIDED 0 4,09-87 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 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 n1lX/v PERMIT FEE I certify that I have read this application and state that the VV \ )) above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, an ereby authorize repres tives of this County ter TOTAL. FEE nZ ve-mentione p o rty for inspection pu o s. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permltt a at WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION CE 875 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 /// p ADDRESS (p(p r" Certified copy is hereby furnished. AIUILDING9LOCALITY ADDRESS Certified copy is filed with the county building inspection O ALITY NEAREST department. cROS s sT. Date Applicant NEAREST DISTRICT NO. GROUP PE ROC SSED BY CROSS ST. CO T, 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.) SI OF LOT IEXISTING BLDG.USE OF 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 v.I., OWNER �j es v so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP MAIL Eil] O A DRESS L �� V Date Applicant L„ rEL. OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY 7-, C, No.a �2 7 Exemption, you should become subject to the Workers' Z 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 GEOOGY INSPECTION E] No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices 0 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. or EXITS ness and Professions Code, and my license is in full force and effect. PARKING REO'D O PROVIDED D SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ❑ 1 am exempt from the licensing requirements as I am a 'ROM: TO: licensed architect or a registered professional engineer SIZE or NO. OF INECTOR'S acting in my professional capacity (Section 7051, Bus- Ex TING BLDG. STORIES SS NATURE iness and Professions Code). FINAL APPROVAL a� ESENT USE Or BUILDING Lic.or Reg.No. Date PR � r � HOME OWNER-BUILDER DECLARATION NO. Or 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 ❑ 1, 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). CONSTRUCTION LENDING AGENCY PROPOSED USE OF UILDING 7 3 Q 5 A I hereby affirm that there is a construction lending agency ` ^ n 0ry� # E E 8 8 for the performance of the work for which this permit is �\ issued(Sec. 3097,Civ.C.). `\ E Lender's Name P 0 623-87 Lender's Address dC PERMIT FEE PROPOSED MAX. OCC. 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 au orize represent ives of this County to enter TOTAL. FEE � a 0 u n th ov - ention d pro 'rty_fur ns t' n rposes. SE REVERSE FOR EXPLANATORY LANGUAGE 2z $- ? Signature of Perm tee ate WORKERS'COMPENSATION DECLARATION 76M444 M I SC E L LA N EO U S APPLICATION {� LJ I hereby affirm that I have a certificate of consent to self CE 875 (11-84)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 FI LL IN BUILDING ADDRESS Certified copy is hereby furnished. Bl1ADDRILDESSING I ` LOCALITY b 0 Certified copy is filed with the county building inspection LOCALITY \ NEAREST department. V_ 111Y L� t CROSS ST. Date Applicant NEAREST ` ♦w DISTRICT NO. G OUPTYPE CESSED BY CROSS ST. p� �" • ' , A CONST. n CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Lee �j COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY rv.. (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 XISTING BLDG. I certify that in the performance of the work for which this 1� ��, o permit is issued, I shall not employ any person in any manner OWNERQF By i ICS I Lri Ej Z 11(1aVk so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP -a o ADDRESS 1--- Date Applicant LUIJ NOTICE TO APPLICANT: If, after making this Certificate of CITY TN0�L. 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION occuPwNcr INSPECTION EJ PiDevices 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 IM� �jj des effect. �l�t tt PARKING SPACES REp'D PROVIDED �y. License Number Lie. Class �c �^ n�S ��U��'1 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 INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING 7fs-] Lie.or Reg.No. Date ✓`�� HOME OWNER-BUILDER DECLARATION NO. OF EXIST � BUILDING II O + ON LOT AND USE I hereby affirm that I am exempt from the Contractor's (� q 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). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING I hereby affirm that there is a construction lending agency d LFz for the performance of the work for which this permit is n issued(Sec. 3097,Civ.C.). B \ \ QU Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE , 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, ere thorize representatives of this County to enter TOTAL FEE i00 upo e a v - ned property for inspection purpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE Signat a of Perm(t a Date WORKERS'COMPENSATION DECLARATION 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'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab.C.) C PoliWic81-0062-.7ZomPan y rtl-p nt �� FOR APPLICANT TO FILL IN ABUILDING DDRESS ❑ Certified copy is hereby furnished. _ADDRESS �j 1 LOCALITY F1 Certified copy is filed with the county building inspection ve 77 department. LOCALITY Temple City, CA CRASS sT. Date Applicant NEAREST DISTRICT NO. GR UP TY IPROCE!JISED BY CROSS ST. Came] 1 is �— �/ �_ ) CON T.. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o COMPENSATION INSURANCEDESCRIPTION LOT NO. BLOCK MAP ^ HIGH WAV rvo. 44'� (CIRCLE) STATE MAJOR SECOND LOCAL } 34 NO. OF BLDGS. rZ (This section need not be completed if the work involved TRACT 6561 NOW ON LOT USE ZONE I SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE OF V 25 t (� I certify that in the performance of the work for SIZE OF LOT tX 110 EXISTING BLDG.which this X permit is issued, I shall not employ any person in any manner '" OWNER John H. & Patricia Peebles ll_ . 0 so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP �O D" (, ADDRE559 'Z E w Date Applicant t1 NOTICE TO APPLICANT: If, after making this Certificate of CITYTpmplp NO. 9gr 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. Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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. REQ'D � PRO ��11 VIDED SPACES License Number Lie.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�aTtl INSPECTOR'S acting In my professional capacity (Section 7051, Bus- EXISTING BLDG-251 X 1101 STORIE SIGNATURE iness and Professions Code). FINAL APPROVAL p PRESENT USE OF BUILDING 1 -13—ir C/ Lie.or Reg.No. Date V HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE one 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 2 rJ 0.7 A SPACES PROVIDED I, as owner of the property, will do the work and the FRall #{ • • • • 8F, structure is not intended or offered for sale (Section 7044, Business and Professions Code). s o • • • • • z PROPOSED USE OF BUILDING Travel AgGRGY CONSTRUCTION LENDING AGENCY VO4-82 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 25,00 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 t0 City Of Temple City) and hereby authorize representatives of this County to enter up g- th abode-menti I property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE S.,0ature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION 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 FOR APPLICANT TO FILL IN ADDRES5 ❑ Certified copy is hereby furnished. u1LDING fp L 1 r S_T J N S pg, LOCALITY DDRESS 1+ ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITYTIC Ji F LC C.I I CROSS ST. Date Applicant NEAREST A DISTRICT NO. G UP CONS PRO SSED BY CROSS ST. ` F',� LL �' /?vc' CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL • v COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP HIGHWAY (CIRCLE) STATE MAJOR SECOND LOCAL Q (This section need not be completed if the work involved NO. OF LOT USE ZONE SPECIAL CONDITIONS P TRACT NOW ON LOT 0 by the permit is for one hundred dollars ($100) or less.) USE OF V SIZE OF LOT EXISTING BLDG. cc I certify that in the performance of the work for which this O permit is issued, I shall not employ any person in any mannerLU NER so as to become subject to the Workers' Compensation Laws. AIL /-// OCCUPANCY GROUP .s U DRESS Gli /�� I V/T•/S ��. rG tl Date Applicant N TEL. „ NOTICE TO APPLICANT: If, after making this Certificate of TY " L NO. gTj_ 7y't7 OCCUPANT LOAD z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with Such provisions or this permit Shall be TRAILER USE GEOLOGY INSPECTION ❑ 1:1 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 [I (LIST ITEMS BELOW) NO. OF EXITS ❑ 9 (commencing with Section 7000) of Division 3 of the Busi- ness nd Professions Code, and my license is in full force and effk PARKING. PROVIDED SPACES REO'D �J Licc o Number Lic.Class LIMITED TIME USE Cont actor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a PROM: TO: 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). .L FINAL APP R O V A L SENT USE OF BUILDING OM ,/� I '�J�� �-(6 1©� �. Lie.or Reg.No. Date N' 1� _( i 41 I S=� LI ;Ruts: t 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 ❑ 1, as owner of the property, will do the work and the 0 8J,2 A structure is not intended or offered for sale (Section 7044, Business and Professions Code). # • • • • 8 8 )�-=-O.EDUSE OF BUILDING CONSTRUCTION LENDING AGENCY V ; N •.• • • • • • z I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 03.30-83 issued(Sec. 3097,Civ.C.). 2 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 IDe above-mentioned\property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE of 3.1q, S 3 Signature of Permittee Date WORKERS'COMYENSATION DECLARATION 87576M444 (2-80) CE � CE 875 M ISC E LLA N EOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION inf,ure, or a certificate of Workers'Compensation Insurance,or 'fl a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILRDEING 01 ZV /J ❑ Certified copy is hereby furnished. jo BUILDING �. / LOCALITY Eldepartment. �„�. �4/ryWY.f Certified copy is filed with the county building inspection • NEAREST department. LOCALITY CROSS ST. Date Applicant ARE ST DISTRICT NO. GR���]]]UP TYPE PROC SED BY CROSS ST. ( (� i CONST, / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL U `J COMPENSATION INSURANCE DESCRIPTION Lo o. BLOCK MAP HIGHWAY >' ND. (CIRCLE) STATE MAJOR SE OND LOCAL Q. NO. OF BLDGS. O (This section need not be completed if the Work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS U by the permit is for one hundred dollars ($100) or less.). USE OF SIZE OF LOT EXISTING BLDG, tr 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,,6WNER cto U so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP UJI ADDRESS ' d Date Applicant rn NOTICE TO APPLICANT: If, after making this Certificate of CITY V NOL OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLI TION 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 ID No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) ❑ NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code, and my license is in full force and PARKING. effect. SPACES ' REQ'D D PROVIDED D 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 SIGNATURE iness and Professions Code). RESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date NO. OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION 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 usi- z n e55 and P[OfeSS10RS Code): NO. PARKING SPACES PROVIDED ❑ I, as owner of the property, will do the work and the 0 4,2 4=8 b structure is not intended or offered for sale (Section 7044, Business and Professions Code). FROPOSED 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 PRoroseo MAX. OCC. Lender's Address PERMIT FE `7✓Jyp)v I certify that I have read this application and state that the L 1 above information is correct.I agree to comply with all County ISSUANCE FEE J ordinances and State laws relating to building construction, TOTAL FEE nd hereby authorize representatives of this ounty to enter po e ab v`e-m d(/r(o[jp/erty for ins ectio purl/p�os�e{�sf. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date p� p y„ W,ffiCE 87 RKERS'COMPENSATION DECLARATION I 5 I (2-80 ) o V u I S C E L LA N E O U.S APPLICATION I hereby 'afert that I have certificate of consent to Self COUNTY OF LOS ANGELES I BUILDING AND SAFETY DIVISION insure, c or a certificate of Workers' rs'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) I If Policy No. Company II FOR APPLICANT TO FILL IN ADD ess uu✓ ❑ Certified copy is hereby furnished. UILDING'\ O�/� /�s. '� �a�s LOCALITY �/tvv A RESS 7 !o I.Certified copy is filed with the county building inspectiopNEARESTLOCALITYdepartment. _� CRossST. qjj(� Date Applicant AREST ;DISTRICT NO. G P TYPE PR SED BY CROSS ST. i �` CONST.. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL \ IV/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK�. MAP HIGHWAY } Ivo. (CIRCLE) STATE MAJOR SEC NO LOCAL NO.,OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT `^\, USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.!) ' USE dF - SIZE OF LOT EXISTING BLDG. ;f 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 o NER /1/ 4P .r— .t .Je SI V so as to becomome subject to the Workers' Compensation Laws. MAIL (� f ) /71 OCCUPANCY GROUP W ADDRESS /��+ • RS (��•/TIII� CCL L Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of too CITY�"r gF �jT NEL. 'I OCCUPANT LOAD Z Exemption, you should become subject to the Workers' q,7' ATION FORT ! EXIT HARDWARE: Compensation provisions of the Labor Code, you must.forth- with comply with Such provisi6ns or this permit shall be TRAILER USE[—] GEOLOGY INSPECTION� , .NO Spec. Knowl. ❑ deemed revoked. ' Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (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 PARKING: effect. SPACES REq'D E= PROVIDED License Number Lic.Class • I LIMITED TIME USE Contractor Date DATE DATE ❑ I FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus-, (STING BLDG. STORIES S NATURE iness and Professions Code). le 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- NO.PARKING ;9309.'8A ness and Professions Code): SPACES PROVIDED ' '❑ I, as owner of the property, will do the work and thej # o o o o 8 8 structure is not intended or offered for sale (Section I I 0 0 0 0 0 0 o in 7044, Business and Professions Code). / ([ i PROPOSED USE OF BUILDING IS IgS �d'C�.'�' • CONSTRUCTION LENDING AGENCY /T ,J (109-85 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.). i Lender's Name ' PROPOSED MAX. OCC. I Lender's Address PERMIT FEE I certify that I have read this application and state that the j. ` above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, d hereby authorize representatives of this County to enter TOTAL FEE \` u on the 'bo a mentioned pro rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE dl-aApyu, 710/0— /— ,Q3 �I Sigilat e Per ittr�, � . Date WORKERS'COMPENSATION DECLARATION rE 875(11-84) M ISCELLANE�JlJS APPLICATION insure, affirm that I have a certificate of consent tself COUN 4Y OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or , a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company , FOR APPLICANT TO FILL IN BUILDING ./�.�• Certified copy is hereby furnished. I XX 4DDR ESs 66 A4$ X � �T` LOCALITY ECertified copy is filed with the county building inspection_ LocALITY NEAREST department. SIX CROSS ST. Date Applicant ROSS ST DISIRICToNO, UP TYPE .T ip ESSED BY CROSS ST. � / %(^ � r Offjj CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP; HIGHWAY STATE MAJOR SECOND LOCAL NO.I (CIRCLE) (This section need not be completed if the work involved TRACT IN O;V ONL OT S. USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) US E OF ' SIZE OF LOT EXISTING BLDG. 1 I certify that in the performance of the work for which this o permit is issued,I shall not employ any person in any man X OWNER of building /j so as to become subject to the Workers' Compensation La s. ;/MAIL /�, /OCCUPANCY GROUP o ADDRESS 4 S 'TL V-ts JAZ Z3 Date Applicant L�.J mg I C TEL.���'Z(P '�6 OCCUPANT LOAD NOTICE TO APPLICANT: If after mak' this Certificate of j CITY !` No. "- 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 USE1:1 EJ Ei F GEOLOGY INSPECTION El No Spec. Knowl. deemed revoked. i ' � LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices - I hereby affirm that I am licensed under provisions of Chapter ' SAFETY PERMIT L-,�(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 a effect. N, X Vame of business PARKING SPACES REQ'D E:= PROVIDED License Number Lic. Class j C b+ �`rer��l LIMITED TIME USE Contractor Date I ( DATE DATE FROM' TO' I am exempt from the licensing requirements as I am's licensed architect or a re NO.OF registered professional engineer slzE OF INSPECTOR'S p g SIG ATURE acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES iness and Professions Code). FINAL APPROVAL Lic.or Reg.No. Date PRESENT USE OF BUILDING { `P HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS O I•��) ON LOT AND USE ��� ,1�✓ 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): 4 No. PARKING I, as owner of the property, will do the work and the 1 SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING i 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 25.001 1 certify that I have read this application and state that the • above information is correct.1 agree to comply with all County I ISSUANCE FEE ordinances and State laws relating to building construction, 1, j " ZJr and hereby authorize representatives of this County to enter TOTAL FEE QQ . upon the above-mentioned property for inspection�oses.I SEE REVERSE FOR EXPLANATORY LANGUAGE XXS'Signature of ermittee WORKERS'COMPENSATION DECLARATION ;Z4;0 3DPw12/90 e-i15UE,L.1. ANE-®y.5 APPLICATION 1 I hereby•affi t_ ificate bf consent to self COUNTY OF LOS'--ANGELES BUILDING:.AND SAFETY DIVISION ; jNmsu r-a certificate of; r ensation Insurance,or ed•copy thereof(Sed.3800 Lab /Policy'No. • - Company FOR APPLICANT TO FILL IN BUILDING I UILDING.ADDRESS /r ADDRESS Certified copy.is hereby:fur I g f�(�'/ L�/ 7?.t�¢� (/j�(� LOCALITY Certified co iled the county building inspect, CITY ZIP 1 department. vb. l e Ci 9/7 ck) CR SS ST. t:.:.: ,. Date +' Applicant i SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS' I coNsr. ( I COMPENSATION INSURANCE TRACT BLOCK LOT NO. MAP _ HIGHWAY (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL I NO. (CIRCLE) STATE MAJOR SECOND LOCAL.. by the permit is for one hundred dollars ($100) or less.) USE ZONE SPECIAL CONDITIONS I ! fADDRESS �Y er TEL NO. I I.certify that in the performance.of the work for which th' i A)v dF C • 6zG ra5�/31i 3/ permit is issued;I shall not emplby'any person in any mann ; ! so as to become subject to the Workers' Compensation Laws. vv OCCUPANCY GROUP 6.0 K[uA�et �- ( I Date Applicant . CITY ZIPS 8v NOTICE TO APPLICANT: If; after making this Certificate T�''K /e ��� �� of Exemption, you should become subject to the Workers' A PLICATION FOR OCCUPANT LOAD Compensation provisions of the4ibor Code,you must forthwith EXIT HARDWARE: 1 comply with such provisions or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ t revoked. I ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[ I Panic Devices � ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) g { I 9(commencing with Section 7000)of Division 3 of the Busine No.of EXITS and Professions Code,and my license is in full force and -I'-- and e o ns ess aiPARKING• REq'D � PROVIDED O License Number Lie.Class I / �a�alen �/� tisPACEs l I I Contractor Datey LIMITED TIME USE ❑ I am exempt from the licensing requirements as I yam S "' (FROM: DATE TO. DATE n licensed architect or a registered professional engineer acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S I and Professions Code). I EXISTING BLDG. s r�/ S .S• STORIES SIGNATURE. Lic or Reg No. Date + PRESENT USE OF BUILDING FINAL APPROVALtiv Sf Gt�vrt�vt GC�foCCu I 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 6Lt /d 3 -e.1 Q K)� ' ( Professions Code): 1 N0.PARIRINGSPACES PROVIDED i ❑ I, as owner of the property, will do the work and th structure is not intended or offered for sale(Section 0 OPOSED USE OF BUILDING Business and Professions Code). r i CONSTRUCTION LENDING AGENCY S stcc ;+ �' • I hereby affirm that there is a construction lending agency for �/i� � moo— -L the performance of the work for which this permit is issued ( I ` (Sec. 3097,ay.C.). I PROPOSED MAX.OCG Lender's Name LICANT rPPoNT) TEL NO. I , ie�-ec•e Zvi Nalo'f/3936 I •- Lender's Address1I DDRESS lz�(• I certify that I have read this application and state thai the �Og AtAK-Y �c '!"e- 7—C. -717 i above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws ielating to building constructioril.and hereby authorize representatives.of this County to enter ltpon ISSUANCE FEE +, the abov - ntioned pro ection purposes TOTAL FEE , . X /0 Z 17-0 Z SEE REVERSE FOR EXPLANATORY LANGUAGE J L I ture of Permittee Date ) I �} WORKERS'CUMI'1✓NJAltutvLCI.LAKHiiVIV I -ooe3DPva: - ­ lY.l-1�l�GLLH11l�uVk2 P%r— av �e I-;AI I I ' L 2o I I hereby.affirm that I have.a certificate bf consent to,self COUNTY OF LQ ANGELES = .BUILDING.AND SAFETY DIVISION ' uinsurc;or a ceitificate of;Wd'fkers'Compensation Insurance,or .;; { -a CertOied copy thereof (Seri'3800,Lah C.)�' ! - - _ Policy'No. Compiny -FOR APPLICANT TO FILL:IN BUILDING .^Y• A. BUI IP(CsADDRESS j'ADDRESS '.I ❑ Certified copy.is hereby:furnished. I I I ocAIJTY ❑ Certified copy is filed with the county building inspectio CITY� V_- ' NEAREST, ' I department ` r CROSS ST. Date 'Applicant SIZE OF LOT N ,OF'HCDGS.NOW ON LOT I, DIS_TRICT NO. GROUPC CONST. PROCESSED BY d CE.=JC?,TE OF-EXEMPTION FROM WORKERS' O TRACT 'BLOCK LO7N0. i I :•. COMPENSATION INSURANCE I MnP - ."Ic"`""r (� yo. (CIRCLEI STATE MAJOR SECOND LOCAL_ ('(Itis section need not.be completed if the work involved' ASSESSOR MAP BOOK PAGE PARCEL 'IiSE ZONE SPECIAL CON PITIONS by the permit is for one hundred dollars ($:100) or less.) I '' j+ r•. er TEL NO. I I ceitify'that in the performance.of the work for whichlth' _ I I permit is issued.'I'thall not employ'any person in any mann I w I pe ADOR OCCUPANCY GROUP so as to become subject to the Workers' Com nsation 'I ws. Z Date Applicant . NOTICE TO APPLICANT: If; after making this Certificate Tin ci7 E ' zIP 19M I OCCUPANT LOAD of Exemption. you•should become subject to the Workers' APPLICATION FOR /' EXIT HARpWARE: -Compensation provisions of the-Iialior Code.you must forthwith comply with such provisions or'this permit shall be-deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ revoked. LICENSED CONTRACTORS DECLARATION I OCCUPANCY INSPECTION C$ ,. Panic Devices ❑ I hereby affirm'that I am,licensed under provisions of Chapter' SAFETY PERMIT❑ (LST ITEMS BELOW) NO.OF EXITS 1 9(commencing with Section 7000)of Division 3 of the Busines ame uslness and Professions Code,and my license is in.full force and e.. c • • jPARKING• REWD D PROVIDED D License Number Lic.Class I SPACES ' I I Contractor Date j LIMITED. TIME DISE I I I DATE DATE ❑ I am'exempt.from'the licensing requirements as I am a FROM: TO: licensed.architect or' a•registered profpssional engineer acting in my professional capacity(Section•7051,Business SIZE OF NO.OF ' INSPECTOR'S I and Professions Code). I' DUSTING BLDG. STORIES i .SIGNATURE. Lia or Reg.No. - Date PRESENT USE OF BUILDING FINAL APPROVAL ! ` ' HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS • ON LOT AND USE ' I hereby affirm that I am.exempt from the Contractor's License Law for the following reason (Section 7031.5, Business land I ' Professions Code): NO.PARKING SPACES PROVIDED, i ❑ I, as owner.of the property, will do the work and,$ 4 - structure is not intended or offered for sale(Section I RO POSED USE OF BUILDING Business and'Professions Code). CONSTRUCTION LENDING AGENCY _ j i' • I'hereby affirm-that there is a construction lending agency, for tht: performance of the work for which this.permit is ised . ' °, i (Sea 3091,Civ.C.).. I PROPOSED MAX.OCG -Lender's Name I 'PP v� �mrr) ' Lender's Address ! DD N�• j I certify that.1 have read this-application and state thadthe L ' above information is correct I agree to comply with all County .PERMIT FEE •.• _ ! ordinances and State Iaws relating•to building,constiuction,(add hereby authorise•representatives.of,this County to enter upon ISSUANCE FEE I sem' I the above-mentioned property for ins ection u. I°;;t•.� P . p P.rposes. ..•. .:.. . j TOTAL FEE .': SEE REVERSE.FOR EXPLANATORY LANGUAGE Signature of Permittee Date , i WORKERS"'COMPENSATION DECLARATION 20-0063DPW12/50 MISCELLANEOUSp►PPL1t.P►1 lUlil 1 hereby affirm that 1 have a certificate of consent to sell COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION -F- insure.or a certificate of Workers'Compensation Insurance.or 1` y a certified copy thereof(Sec.3800. Lab. C.) BUI Policy No. Company FOR APPLICANT TO FILL IN lIDDRESs `/ } 1 BUILDING ADDRESS ..((.11.. ❑ Certified copy is hereby furnished. b 6 ( LyAs--t�ncv_5 Dr- �ti'�— TocALtTY ❑ Certified copy is filed with the county building inspection ( CITY //'- LIP/ d Q Q� ZIEAREST department. I T ytti t 7 C!l ! 1 -' � CRoss sr. Date Applicant Z SIZE OF LOT NO.OF SLOGS.NOW ON LOT ISTRI No GR UP TYPE -EBBED BY CONST. CERTIFICATE OF EXEMPTION FROM '*YORKERS" TRACT BLOCK LOT NO. f ) COMPENSATION INSURANCE AP eI HWAN STATE MAJOR SECOND LOCAL ! (This section need not bi completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL IJSE zoNE SPECIAL CONDITIONS by the permit is for one hundred dollars (51001 or less.) _ i OWNER ' 0hv% &P6Ltri c,Y6tt I TEL NO. 1 I certify that in the performance of the work for which this properly ee S permit is issued. I shall not employ any person in ...... manner J so as to become subject to the %%,orkers' Compensation Laws. } ADDRESs9IPG 1 �$7u►�QLS r� OCCUPANCY GROUP { Date ApplicantCITY LIP I NOTICE TO APPLICANT: If. after making this Certificate`I T� �e- G I � I �) � � OCCUPANT LOAD of Exemption. you should become subject to the Workers" APPL .4TION FOR EXIT HARDWARE: Compensation provisions of the Labor Code.-you must forthwith comply with silcb provisions or this permit shall be deemed TRAILER USE_I GEOLOGY INSPECTION D ! No Spec.KnOwl. ❑ P revoked. _ OCCUPANCY INSPECTION'_1 Panic Devices LJ LICENSED CONTRACTORS DECLARATIONiirr'�� ' 5 , 1 hereby affirm that I atn licensed under provisions of Chapter t SAFETY PERMIT0 (LIST ITEMS BELOW I 1 ❑ 9 Icomntencina with Section 70001 of Division ?of the Business No.of EXITS and Professions Code.and my license is in full force and effect. 1.t}H�C�� tt L{-kr orbs PARKING• REG'D I PROVIDED € License Number Lic. Class � SPACES + Contractor Date LIMITED ' TIME USE DATE DATE i ❑ 1 am exempt from the licensing requirements :ts I am a To: a licensed architect or a registered professional engineer4 I• INSPECTOR'S ` acting in nit' prof ssibnal capacity(Section 70 1. Bll51ne55 3EXISTOING BLDG. I STORIES I � SIGNATURE I _ and Professions Code). 1111 a t� 1 LI:.Or Rei N0. Date, X PRESENT USE OF BUILDING e.0.1 Fll'JAL APPROVAL rs• !1 HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License'' a Law for the following reason (Section 70315. Business and Professions Code): IND.PARKING SPACES PROVIDED ❑ 1, as owner of the property. will do the work and the I I structure is not intended or offered for sale(Section 7044X 1PROPOSED USE OF BUILDING I.`• Business and Professions Code). y r✓ U nL Irk. C` T ` • CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance df the work for which this permit Is Issued I PROPOSED MAX.OCG ' (Sec 3097•Civ.C.). I Lender's Name 4PPLICANT(PRIMP TEL NO. Lender's Address kDDRESS j 1 certify that 1 have read this application and state that the �I above information is correct. I agree to comply with all County �ERMIT FEE ordinances and State laws relating to building construction•and I �;• Thereby authorize representatives of this County to enter upon SSUANCE FEE 1 I the above-mentioned property for inspection purposes. L� OTAL FEE 1 Kit. If 7( 1� 1,��'^" 'r '` I AD SEE REVERSE FOR EXPLANATORY LANGUAGE l' i Signature of Permittee Date • I i I ,