HomeMy Public PortalAbout9663-9665 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION ; CE 876(1 1-84) MISCELLANEOUS A P P L I C AT I O N •
I,sure,bo affirm that I have a certificate of consent to c 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.Q.
Policy No." CompanyFOR APPLICANT TO FILL IN BUILDING
c ADDRESS
Certified copy is hereby furnished. DING 5 E L s -Tum y LOCALITY
ADUILDRESS !1
Certified copy is filed with the county building inspection
department. OCALITY 1 AS -R1`►1/�S NEAREST
—RCNAS/'J CROSS ST.
Date Applicant RAREST w� L,�*� DISTRICT NO. GROUP ITYPE PROCESSED BY
055 ST. H M Iv AVE:y 1CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
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
I certify that in the performance of the work for which this sI OF LOT EXISTING BLDG. O
permit is issued,I shall not employ any person in any mannerLl i
so as to become subject to the Workers' Compensation Laws. pwNER LLf S OCCUPANCY GROUP' 04
Date Applicant ODRESS �� E. LAS TUNAS �2. w
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEMPLE C ITvoL'(�(S� OCCUPANT LOAD y
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. I I
Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PER MI ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- No. of Exlrs
nese and Professions Code,and my license is in full force and yR 1t I�#0 b)!_1t� �vL�.
effect. 1L% /t 9 PARKING SPACES REq'D PROVIDED
License Number Lic. Class r
LIMITED TIME USE
Contractor Date SiA I I H DATE DATE
❑ I am exempt from the licensing'requirements as I am a FROM: TO:
licensed architect or a registered gm INSPECTOR'S
gi professional engineer eer slzE of NO. OF
SIG TORE
acting in my professional capacity (Section 7051, Bile- EXISTING BLDG. STORIES
mess and Professions Code). FINAL APPROVAL 01
Lic.or Reg.No. Date RESENT USE OF BUILDING
comAurEws7'o E
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 p
El 'I, as owner of the property, will do the work-and the
SPACES PROVIDED �9 8 a 6 A
structure is not intended or offered-for sale (Section # o o e o 8 8
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING o 0 0 0 0 0 o z
I hereby affirm that there is a construction lending agency C'Q/l/J (,� cS7'O/P� 0� 7 0•=88
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCG. '
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
d hereby authorize representatives of this County to enter TOTAL FEE
C15 10 U
on the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION SCE 87b(11-84) M p�CELLANEOUS APPLICATION
I hereby affirm. cat 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.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. DRESILDINS v 1�G `4r / n� LOCALITY
'leAD
Pit
ElCertified copy is filed with the county building inspectionLOCALITY /� NEAREST
department. -.Q rK ; CROSS ST.
Date Applicant ;WAREST DISTRICT NO. G TYPE PRO SED BY
CROSS ST. T. I
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �V/
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND OCAL
NO. (CIRCLE)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOTUSE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. d
0
permit is issued,I shall not employ any person in any manner OWNER ex
so as to become subject to the Workers' Compensation Laws. IL OCCUPANCY GROUP (/
ADDRESS 0.
7,124-
Date Applicant
TEL. OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY AIA&m`j t 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 USE GEOLOGY INSPECTION ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
El
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. PARKING REq'D PROVIDED
SPACES
License Number Lie. Class
• LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE SOF NO.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGN TORE
iness and Professions Code).
RESENT USE OF BUILDING FINAL APPROVAL
Lie.or Reg..No. NIo. Date _ z i
COI r
HOME OWNER-BUILDER DECLARATION No. OFO EXISTING BUILDINGS 8 6 a�!A
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's # 0 0 0 0 8 8
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 co mp t4 TI-IZI
for the performance of the work for which this permit is \
issued(Sec. 3097,Civ.Q. 1 \
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE 1 d�
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 ereby authorize representatives of this County to enter TOTAL FEE
u thea ave-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION CE 875
(11-84) MISCELLANEOUS APPLICATION
or affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
re, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL.IN BUILDIENG `
AD OR SS
Certified copy is hereby furnished.t- BUILDING q LOCALITY
ADDRESS Dr,
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT I�Q' G OUP TYPE / PROC SED BY
V CROSS ST. ('�/ CONST. l /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL lll///a YY
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP ;HIGHWAY STATE MAJOR SECOND LOCAL
NO. �� j (CiR CL6)
(This section need not be completed if the work involved TRACT Now NL OT S. USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
permit is issued,I shall not employ any person in any manner OWNER S�
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP -• o
Date Applicant ADDRESS � r W
T >N_411 OCCUPANT LOAD a-
NOTICE TO APPLICANT: If,after making this Certificate of clrY No. y
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: a
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions oI this permit shall be TRAILER USE [:] GEOLOGY INSPECTION Eldeemed revoked. ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING
SPACES REQ'D PROVIDED
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATEC OA TE
FROM.
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO.OP INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S NATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING ✓
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXI TING ON LOT ANUSE B ILDI S
I hereby affirm that I am exempt from the Contractor's 27210 A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING # — o o 88
ElI, as owner of the property, will do the work and the SPACES PROVIDED •o o 1 0 0 0 0 o z•
structure is not intended or offered for sale (Section
7044,Business and Professions Code). 0615-87
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUIL N
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. �(J
Lender's Name PROPOSED MAX. OCCLender's AddressI ertify that I have read this application and state that thePERMIT FEE bah
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,i
u n t bov - entioned prope y`or inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
—Sigifalure WP6mittee Date
i
WORKERS COMPENSATION DECLARATION 76M444
7� !-r CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm,that I have a certificate of consent to self I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.).
BUILDING �f /j
Policy No. Company FOR APPLICANT TO FILL IN v u
ADDRESS �
Certified copy is hereby furnished. AnORES �� L�VI d( Yi LOCALITY g-
El Certified copy is filed with the county building inspectionO ALIrY e ° NEAREST
department. _al I CROSS ST. ;
Date Applicant EAREST �I^ DISTRICTjjj OUP TYPE PR(. SSED BY
CROSS ST. ` �T'�// ,�I CONST. /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J(U (�/ 7Y/
COMPENSATION INSURANCE DESCRIPTION LOT No. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR S COND 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.) us a OF
S 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 ICL VI C wam 0u 111)
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
ADDRESS r
Date Applicant AIL D �1 n j IU
NOTICE TO APPLICANT: If,after making this Certificate of CITY �I �yyl,i��-�� No•. lG�11 J��[ / I OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR /l? EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shall be E U
TRAILER SGEOLOGY INSPECTION ❑
❑ ❑ No Spec. Knowe.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
EJ
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 0 E:= PROVIDED
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: - TO:
D I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer slzE of NO. OF INS P rOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL i
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING �8 9 Q 7 A
0 I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section # o e o e 3 0
7044,Business and Professions Code). D 0 o D Io 0 0r13
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING� 0219-88
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is J Q
issued(Sec. 3097,Civ.Q.
Lender's Name -'
PROPOSED MAX. QCG. � I> P� �
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 uthorize representatives of this County to enter TOTAL FEE
u n`61 ve-mentioned p y r inspection purposes.
/ t !�,�`(� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date (� ��
WORKERS'COMPENSATION DECLARATION
CE 875(11-84) MISCELLANEOUS APPLICATION
.v 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�tgrtified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS .
1
FICertified copy is hereby furnished. BUILDING r
ADDRESS , LOCALITYiYl
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. '� CROSS ST. t%jvj'�
Date-Applicant NEAREST �� DISTRICT G$OUl� TYPE / PRO S ED BY
�..� CROSS ST. �Lt/I, l/ -t'.yr 5,F&VV .�J CONST j]//
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL b (/
I COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SEC O LOCAL
NO. (CIRCLE)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF ��
SIZE OF LOT EXISTING HLD G. '
Zf
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 ..1 I OWNER =O
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
ADDRESS I Z5
Date Applicant ( 1.1
NOTICE TO APPLICANT: If, after making this Certificate of�9 CITYAft C%— TE
OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: _
Compensation provisions of the Labor Code,you must forth- E]with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION E] No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION(x Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING REq'D PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
0 I am exempt from the licensing requirements as I am a FROM. TO:
licensed architect or a registered professional engineer SIZE OF NO.OF, I PE CTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IGNATURE
iness and Professions Code). , FINAL APPROVAL
PRESENT USE OF BUILDING (f
Lic.or Reg.No. Date i
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS z 6 8 9 7,A
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's # G D,o.0 8.8
License Law for the following reason (Section 7031.5, Busi-
ness
usiness and Professions Code): NO. PARKING o D•G Doo•o a
EJI, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for We (Section 0 4,-2 4,-i&8 7
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.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address `(
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE
Wignature
laws relating to building construction,
represen ives of this County to enter TOTAL FEE CS.A
boned pr9 A for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Permittee Date a
WORKERS'COMPENSATION DECLARATION CE 875(11-81K 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 // r q�
ADDRESS �I�J 4`l� � KS
Certified copy is hereby furnished.
ADDRESS L'ts7.s��LfrS /!.Ak4'S A9 LOCALITY Lar3
Certified copy is filed with the county building inspection LOCALITYCROSS$T
department. '40, A"CG1 1 .C om?
Date Applicant NEAREST �/�� D'ISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST. /`/rW ST_ 0+D sJ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 'M o� v
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF ]SLOGS.
(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
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
permit is issued,I shall not employ any person in any manner OWNER G' }/v S�(/,J L1L.&I) !oH
so as to become subject to the Workers' Compensation Laws. MAIL /� OCCUPANCY GROUP
Date Applicant
ADDRESS 4.0- VIII wAt v,.LT 2i]kvx- U
W
TEL OCCUPANT LOAD �-
NOTICE TO APPLICANT: If, after making this Certificate of CITY �JA- &4- NO.91f-44.7.the-s rn
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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter I 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 D PROVIDED D
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
0 I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGN TURF
iness and Professions Code). FINAL APPROVAL ����V9z
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
65 ii z?9_r&/ic/ e �,10AI n/
HOME OWNER-BUILDER DECLARATION NO. OF EXI TING BUILDINGS 0 r �'=-•i
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's I-.rll
License Law for the following reason (Section 7031.5, Busi
ness and Professions Code): NO. PARKING
SPACES PROVIDED ;r-•+�: •;I.�l-:;„C:
I, as owner of the property, will do the work and the i 8113 s •.1
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 /i,✓ /fe�S/N�sS i
for the performance of the work for which this permit is If
issued(Sec. 3097,Civ.Q.
Lender's Name ,
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
I certify that 1 have read this application and state that the �Dp
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
TOTAL FEE
iSEE
REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date
I
WORKERS'COMPENSATION DECLARATION ICE 8754(11-a4) MISCELLANEOUS APPLICATION
I hereby affinR,Jhat I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a cert:rlcate of Workers'Compensation Insurance,or
a certifies copy thereof.(Sec.3800,Lab.C.). /` _
Policy No. ' ADDRESS J�Company FOR APPLICANT TO FILL IN BUILDING o3 /2AM( k
Certified copy is hereby furnished. BUILDING / ( , [;� TUNf'� br. LO CALI7Y L RE CITY
ADDRESS 1�v
Certified copy is filed with the county building inspection LOCALITYNEAREST
department. J-F(,J?Lir UTy GA 01(-76O cROSs ST.
Date Applicant NEAREST DIST IC G U�TYPE P CES BY
PP 6�1�U API -L G 5
CROSS•ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL '
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this C)
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 o
ADDRESS E3
Date Applicant / ____ _ �
NOTICE TO APPLICANT: If, after making this Certificat of CITY R0�1+1+,t aD No�'l. OCCUPANT LOAD
oral
Exemption, you should become subject to the Wor ers' --
Compensation provisions of the Labor Code,you must f rth- APPLICATION FO EXIT HARDWARE:
with comply with such provisions oI this permit sh be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. El
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of C apter SAFETY PERMIT ❑ (LIST ITEMS BELOW
9 (commencing with Section 7000) of Division 3 of th Bus!- No. OF EXITS
ness and Professions Code,and_ my licesp iglin gull for a and �NS-
effect. (�1'/V /�` � %vV /I SPACPARK ESG Ra Wo PROVIDED
License Number Lic. Class `0` i LIMITED TIME USE
Contractor ate -7474- i Ar` DATE DATE
I am exempt from the licens re uuelii� t as am a
licensed architect or a registered professional engineer SIZE OF NO. OF PROM. TD. INSPECTOR'S
SIGNATURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
inessand Professions Code). +. ` FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING �Ia I�s ('t 0 2
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- ��}ry `I i{
ness and Professions Code): Nb. PARKING i.l00101-0001 .4 6190
I, as owner of the property, will do the work and the SPACES PROVIDED 8793 1 All 19:47
structure is not intended or offered for sale (Section
7044,Business and Professions Code). �j
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING WPri LS S d
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. � v
Lender's Name 1� - V
PROPOSED MAX.OCC.
Lender's Address 5 LIU '
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, d�}
and hereby authorize representatives of this County to enter TOTAL FEE as
upon the above-mentioned property for inspection purposes.
19 S T �) n SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee�- Date
WORKERS'COMPENSATION DECLARATION
CE 875(11-84) MI I SC E L LA N E O U S APPLICATION
CE 875
I hereby,.•afcert 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,Wrtified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDINGDV
ADRESS
❑ Certified copy is hereby furnished. BUILDING :EM E C;
V ADDRESS 63 e r"v OCA LITY J
❑ Certified copy is filed with the county building inspection.J LOCALITYNEAREST
department. + — CROSS ST.
Date Applicant ` c NEAREST DISTRICT NA. GR-P TYPE / PRO SED BY
V CROSS ST. U FFMA I/ N57/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL YYY
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SEC D LOCAL
(
NO. OF BLD GS. NO. CIRCLE)
(This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. l.�
I certify that in the performance of the work for which this ��JJ o
permit is issued, I shall not employ any person in any manner -4 OWNER O' - + j s44 `�
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
J ADDRESSr-
Date Applicant p.O, 0 7 7 LLI
NOTICE TO APPLICANT: If, after making this Certificate of CITYA-I#pMB&4 GA'Q,1 OA N0- i d _ 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 ❑ 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 PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING REQ'DD PROVID EO D
SPACES
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE pp SIZE OF NO. OF INS ECTOR's
acting in my professional capacity (Section 7051, BuS V EXISTING BLDG. WS0 S �� STORIES I S NATUR
iness and Professions Code).
PRESENT USE OF BUILDING � FINAL APPROVAL —ID
Lie,or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING7
SPACES PROVIDED � 1 J.O
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section # o o*o o 8 8
.7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY -"A PROPOSED USE OF BUILDING l�itS :NGTS
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 `
rj,Ov n
I certify that I have read this application and state that the PERMIT FEE V� "
above information is correct.I agree to comply with all County ISSUANCE FEE o o e o o D o z
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned property for inspection purposes. .��SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of ermittee ate
c
WbRKERS'COMPENSATION DECLARATION
CE 875(11-84) M I SC E L LA N EO U S APPLICATION
� CE 875
I hereby affirm That I have a certificate of consent to self COUNTY OF LOS ANGELES 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 FI LL IN BUILDING y,
1 //��,, t� ADDRESS 663 � ( N � �1
rl Certified copy is hereby furnished. AUILDIN Ea �•I1� (l( Dr `�
LOCALITY Ck 1-V CA q 1396
-F� Certified copy is filed with the county building inspection LO LITY NEAREST
department. L ceoss sr.
Date Applicant EAREST e' DISTRICT.���tIODD OUP PE PR CE SED BY
ROSS ST. ry/�F,..LLIA ` �( ` CONST,
CERTIFICATE OF EXEMPTION FROM WORKERSLEGAL u
COMPENSATION INSURANCE DESCRIPTION LOT NO. NO. OF BLDGBLOCK MAP (CIRCLE)HIGHWAY STATE MAJOR SEC D LOCAL
Ro. cl$.
(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 ($100) or less.) USE D
ZE OF LOT EXISTING BLDG.F
I certify that in the performance of the work for which this ` � o
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY ZZ Ai"i GROUP �j —,2/ a
D DRESS !-•-
Date Applicant `d 6 A, IAJ
NOTICE TO APPLICANT: If,after making this Certificate of ' CITY NO. IOCCUPANT LOAD 1`I_� Ir z
Exemption,• you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shall be TRAILER USE El GEOLOGY INSPECTIONNo Spec. Know].
❑
deemed revoked. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices E
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO, of EXITS
ness and Professions Code,and my license is in full force and
effect, PARKING
SPACES REQ'D PROVIDED
License Number Lic. Class LIMITED TIME U S E
Contractor Date DATE DATE
D I am exempt from the licensing requirements as I am a
FROM: TO:
licensed architect or a registered professional engineer sI ofG NO. OF 0� I$SGECTURE
acting in my professional capacity'(Section 7051, Bus- SE (STINBLDG. STORIES
mess and Professions Code). \�• 1� FINAL APPROVAL
;PR ESENT USE OF BUILDING ` t' /
Lic.or Reg.No. Date 6
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
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 IV AA= act
ROPOSED USE OF BUILDING Qy�
I hereby affirm that there is a construction lending agency A
for the performance of the work for which this permit is ACCT°r
issued(Sec. 3097,Civ.Q. MI CI FEE
Lender's Name
PROPOSED MAX. OCC.
Lender's Address L-1
-y�.1 .I !4
PERMIT FEECQ_50 0U �[l0(�•-Dian(i S! !il/8
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 0297 AM 8:35
ordinances and State laws relating to building construction, O
and hereby authorize representatives of this County tc enter TOTAL FEE
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE &j-O
'Sygnature of Ilermittee Date 1131
WORKERS'COMPENSATION DECLARATION
CE 875 (2-80) MISCELLANEOUS APPLICATION
CE 875
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or IL
a certified copy thereof(Sec.3800,Lab.C.) `
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS 6/1
❑ Certified copy is hereby furnished. AUILDIN �, LOCALITY
❑ Certified copy is filed with the county building inspection Q / NEAREsr
10
department. LocALlry 7'�� / C(✓ C7,)� 6 CROSS ST.
Date Applicant EAREST / ,/ DISTRICT NO. OUP PROCESSED BY
CROSS ST. ST,
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE
DESCRIPTION LOT NO. BLOCK
NO. (CIRCLE) STATE MAJOR SECOND LOCAL >_(� HIGHWAY
NO. OF LDGS. a
(This section need not be completed if the work involved TRACT NOW ON LOT USE ONE S CIAL CONDITIONS 0
by the permit is for one hundred dollars ($100) or less.) U
N USE OF
SIZE OF LOT VD EXISTING BLDG. �/V cc certify that in the performance of the work for which this V 0
permit is issued, I shall not employ any person in any manner J,ATWNER R )
so as to become subject to the Workers' Compensation Laws. AIL Wl
OCCUPANCY GROUP �� `U
AO ADDRESS0.
Date Applicant j TEL d�U� fn
NOTICE TO APPLICANT: If, after making this Certificate of cirY — L No. �767j 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
d ❑ NO Spec. Knowl.
deemed revoked. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) NO. OF EXITS ❑
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
PARKING
effect.
SPACES REO'D I I PROVIDED
License Number Lic.Class LIMITED TIME USE
Contractor Date DATE DATE
❑ I FROM: TO:
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). LY-WfSENT USE OF BUILDING FINAL APPROVAL
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE -F1 8 3,9 A
I hereby affirm that I am exempt from the Contractor's • • • • 8 8
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING • • • • • • •
SPACES PROVIDED 2
❑ I, as owner of the property, will do the work and the ) _8 3
structure is not intended or offered for sale (Section
7044, Business and Professions Code). oPosEO USE of BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency f
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 t correct. I agree tcomply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, TOTAL FEE
and hereby authorize representatives of this County to enter .Q Jof—
upon the above-m tioned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATO AGE
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION CE 875
(11-84) M I SC E L LA N EO U S APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.CJ.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING �(O103
ADDRESS (O
Certified copy is hereby furnished. BADUILDRDENSIG J P. L- 1S U NfIr LOCALITY
S v 6
Certified copy is filed with the county building inspection LOCALITY l qo NEAREST
LOCALITY 1l� CRoss sT.
Date Applicant NEAREST / '` `, yI� r�N/�/'I {`} DISTRIC33 NO. GROUP TYPE PR CESSED BY
CROSS
ST. 'l-NU 1` �=I' , ��� / \ ,('�D� -3 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY
rvo. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPS 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 . C:)
permit is issued, I shall not employ any person in any manner OWNER 0` 61111_,0111e �g . ='
so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP �� o
ADDRESS ,Lf 74- �
Date Applicant uJ
NOTICE TO APPLICANT: If, after making this Certificate of CITY PIL (l/( ( No. 6 OCCUPANT LOAD O_
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 USEGEOLOGY INSPECTION ❑
❑ E] No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force andK S ./��
effect. N PARKING REQ'D PROVIDED
SPACES
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). pp /
PRESENT USE OF BUILDING X ���,+cam w FINAL APPRQV�4„ - /]
Lic.or Reg.No. Date -
.W
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's0000_C 12/- 9.,
License Law for the following reason (Section 7031.5, Busi- =`. �M�
ness and Professions Code): NO. PARKING V" "` 6767 1 FIM 4:418
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section �1
7044,Business and Professions Code). �r
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 /
I certify that I have read this application and state that the PERMIT FEE
',above information is correct.I agree to comply with all County ISSUANCE FEE
grdinances and State laws relating to building construction, 1.01
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above- entioned ty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
SignaturkJof Permittee Date °�/
WORKERS'C'Ob11'ENSAIION DECLARATION '0-000. M15C:ELLANtVl,15 APPLIUAI 1UN
0-UUt�sDPW 12'UO
1 hereby affirm that I have a certifie;tc of consent (,I, self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION I�
insure,or a certificate of Workers'Compensation Insurance,or
it certified copy thereof(Sec.3800. Lab.C.)
J ::ilicy No. _ _• Company FOR APPLICANT TO FILL IN BUILDING
BUILD G ADD ESS ADDREss ty� V 'v 2- 4C�I• •
El Certified copy is.hereby furnished. (; /� L tw_ b XXVVE I LOCALITY
❑ Certified copy is filed with the county building inspection CITYo % ZIP NEAREST
6
'•J department. i t 9/7,;V
CROSS ST. �
Date Applicant SIZE OF LO NO.OF BLDGS.NOW ON LOT I DISTRICT NO. GROUP TYPE PROCESSED BY
I.
CERTIFIC'AIT 01' EXEMPTION FROM WORKLIt's TRACT, / t7 BLOCK LOT NO. CONST. `.
COMPENSATION INSURANCE 1 MAP HIGHWAY
I 1 NO. IGIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work ill"'OIYC111 ASSESSOR MAP BOOK PAGE PARCEL � USE ZONE SPECIAL CONDITIONS r"
by the permit is for one hundred dollars (�IIOUI oil less.)
I
certify that in the performance of the work li,r wit 1 Iliti ow ER ^ t T L o. i
permit is issued. I shall not employ any person in any n{anne I,
so as to become subject to the Workers' Compensation'IL . APID ESQ OCCUPANCY GROUP ® tl
l�./ rid• l�l.l=�- G*�-� I
Date Applicant CIT,
NOTICE TO APPLICANT: If, alter making this Certificate zlP�l.C.a 007 OCCUPANT LOAD
of Exemption• you should become subject to the Whrkers' APPLICATION FOR
Compensation provisions of the Labor Code.you must rorf,hwith EXIT HARDWARE: .
I comply with such provisions or this permit shall be Llremed TRAILER USE GEOLOGY INSPECTION❑
revoked. y p No Spec.Knowl. ❑
OCCUPANCY INSPECTIONILII ' Panic Devices ❑
LICENSED CONTRACTORS DECLARATION
3 I I hereby affirm that I .1m licensed under provisions of Chapter SAFETY PERMIT❑ ILIST ITEMS BELOW,
9(commencing with Section 7000)of Division 3 Of till'BgslneSS NO.OF EXITS
and Professions Code,and my license is in full force and-,'effect. �� t3tNfi55
' PARKING• REQ'D O PROVIDED D
License Number Lie. Class SPACES
Xl/�yNC' oG �'! _,___._• r LIMITED TIME USE
I
Contractor Date t
~ IDATE DATE
❑ I am exempt from the licensing requirements as 11 am a FROM: TO:
t I licensed architect or a registered professional crlgineer
acting Ill Illy professional capacity (Section 7051. 11as'illess SIZE OF NO.OF INSPECTOR'S
and Professions C'ode). E%IS TING BLDG. STORIES SIGNATURE
Lia or Reg. No. _._ _ . _ Date ) PRESENT USE OF BUILDING f,l6;9 V9AJ I FINAL APPROVAL ar
•`•! i HOME OWNER-III.III.DER DFULARAHON I NO.OF uxisrING BUILDINGS
t ON LOT AND USE
hereby afTirn that I am exempt front the Contractor's License
Law for the following reason (Section 7031.5. Business and
I , Professions Code): ; NO.PARKING
SPACES PROVIDED
❑ 1. as owner of the properly. will do the %%ork ;uid the -
structure is not intended or ol'iVred 161 sane(SeelILII 7044. PROPOSED USE OF BUILDING
Business and Professions Code).
I CONSTRUCTION LENDING AGENCY
i1 hereby affirm that there is a construction lending agency lin•
the performance of the work for which this permit is Issued
! (Sec. 3097,Civ.C.). 1 PROPOSED MAX.OCC.
Lenders Name ._........... ...-. _.. APPLIC9NT(FRINT) TE,L}�0. ,
X L£v.-A
Lender's Address l ADDRESS
I certify that I have read this•application and statetl�t the
above information is correct. 1 agree to comply with all(�'ounty PERMIT FEE
I ordinances and State laws relating to building construction.and
j hereby authorize representatives Of this County to enterI upon ISSUANCE FEE
the above-mentioned pro erty for inspection purposes. 1
�•. r TOTAL FEE
o 1 -
c :X I /T �_ SEE REVERSE FOR EXPLANATORY LANGUAGE 1
Id - Signat re o r it
ata
v I .I
I
WORKERS'COMPENSATION DECLARATION 76M444
ICE 875(11-84) M ISCELLANEOUSAPPLICATION
'I hereby affirm that I have a certificate of consent to self , I COUNTY OF LOS :ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or r , �.• 1
a certified copy thereof(Sec.3800,Lab.Q. ` :
Policy No. Company FOR APPLICANT TO FILL IN BUILDING AD &�
DRESS
❑ Certified Copy IS hereby fUInlShed. II BUILDING �j F , � ASTU&f� oQ LOCALITY
X�1� ADDRESS L.r1 �v
Certified copy is filed with the county building inspection I LOCALITY "iEM per. Gi ry 9 rI O OSS GRST.
department. SX
Date Applicant NEAREST JJ�� (w/��� ( ( DISTRICT NO. GROUP TYPE P ESSED BY
CROSS ST. �rC��P,n l j `�I,1 `��^^v .�� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OR BLDGS.
(This section need not be completed if the work Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. '
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner, OWNER of building, Irl LIJ'ki'-6 S(-rl if
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP D'MAIL n
ADDRESS P� O� t r-
Date Applicant {��l w
NOTICE TO APPLICANT: If,after making this Certificate of CITY 4'}A"RA NO. �D I6� OCCUPANT LOAD
Exemption, you should become subject to the Workers' gppLICATION 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 ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
1 hereby affirm that I am licensed under provisionsof Chapter 1 SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000)of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force an X ^
effect. Name of business PARKING REQ'D SPACES JJ�J PROVIDED �_ 1
J
License Number Lic.Class
-1 N IN LIMITED TIME USE
Contractor Date I DATE DATE
EJ1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer f slzE OF qo %a NO.OR PROM. TO. INSPECTOR'S
7 SIGNATURE ,
acting In my professional capacity (Section 7051, Bus- I; EXISTING BLDG. �' STORIES
iness and Professions Code). ' Ap/
PRESENT USE OR BUILDING /� �t�W11 FID IAL APPROVAL
Lic.or Reg.No. Date �} I
IIOME.OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS v Wt
I hereby affirm that I am exempt from the Contractor's ON LOT AND par.
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 ,I SPACES PROVIDED
structure is not intended or offered for sale (Section I ,
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY j PROPOSED USE OF BUILDING NIS
1 hereby affirm that there is a construction lending agency I .p
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name t
1 PROPOSED MAX.OCC. J
Lender's Address Ti
PERMIT FEE 1—� ;i
1 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 FET,
E :t!
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 25.00 1 t.
upon the allpvezmet t" ed property for inspection purposes.
XX XX ' ( SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig aturc of Perinittec Date
WORKERS*COMPI:NSAI'ION DECLARATION :,��M�� 1 ; MISCELLANE061S APPLICATION
sl hereby affirm that I have a certil'icale of ct .ent iy .ell' COUN11' OF ANGI-LI-S liIIILUING AND SAFETY DIVISION
n
insure,or a certificate o1' Workers'C'unlpen.ation Insurance.or
I certified copy iherenl (Sec. 3800. lab. C.)
s Policy No. , • Company �a AQ FOR APPLIGAN I TO FILL IN BUILDING
BUILDJJJ)',pQDRES �- j ADDRESS
❑ Certified cop)' is hereby I'u rnishcd• �[ry� ( � ,�S �(�11�GS l'.� + LOCALITY
❑ Certified copy is filed with the county building hisli ICtion CITY.- ZIP
department. , 1 C1
J NEAREST
�� yv CROSS ST.
Date _. Applicant SIZE OF LOT% NO.OF BLDG .NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY
C'ERTIFICK111: OF EXEMPTION FROM 1VORKLR.t+ CONST. i
�I C'UMPENSXHON INSURANCE ' Tr1ACT BLOCK LOT NO. NAP HIGHWAY t
I NO. ICIRCLEI STATE MAJOR SECOND LOCAL
(This tiE•CI11111 need not be completed If IIIC \\(11'h i1111)I t'l"(I ASSESSOR MAP BOOK PAGE PARCEL t
by Elle' permit is for 011e hundred dollars (S I(3()) 111' Ie%0 USE ZONE SPECIAL CONDITIONS
III OWNER TEL NO. )
,•� iI certify that in the performance of the work fur tthicf� this — �-- I---- - I�- i
permit is issued. I shall not employ any person in any manner I
ADDRESS
so as to become subject to the Workers' C'ompen.atinn Ilatt•s. i OCCUPANCY GROUP
i Dale Applicant CITY ZIP
NOTICE TO APPLICANT: If. alter making this ('eriii'ieate _ OCCUPANT LOAD
of Exemption, you should hCC0IIIC subject to tale W(trkers' APPLICATION FOR EXIT HARDWARE:
C'ompensalion provisions of the Labor Code.you moil Ioriliwith
comply with such prat ilio 1S or this pernlll SINIII he dtfelllCd TnAILER UIE D GEOLOGY INSPECT ION Ll NO Spec.Knowl. ❑
revoked. - p'7-
OCCUPANCY INSPECTIONN I• Patric Devices
❑
'
LICENSED CONTRACTORS DECLARATIONII ^^ 1.
1 hereby affirm (flat 1 amlicensed antler provisions- (11 (II;11)ll'r SAFETY PERMIT IJ (LIST ITEMS BELOW I'' `L
•� I 9(commencing with Section 7000)of Division 3 of the I3lISilless NO.OF EXITSEl
and Prol'essions Code.and my license is in full li)rce and effect. I�IA1_lf c:r +i(-.tnilts`_'i i
PARKING• REO•D PROVIDED
License Number Lie.Class SPACES D
LIMITED TIME USE
IT
Contractor Ua(r - - --- - --'- --
DATE DATE
I ❑ I deet exempt Troll the licensing requirements its I�il111 a FROM: TO:
licensed architect or a registered prulessional en lincer -
•
acting I11 111)' pl•(lf L•titiln11;11 L•ilpill'll) (tit'L'llnit 7(li(. Ittff,Sllll'ti. SIZEOF NO. )F INSPECTOR'S
I• iI EX1srING BLUG. SI'ORIL.S SIGNATURE
- and Professions ('ode). --------- ---
PRESENT USE OF BUILDING
Lie. or Reg. No. Dale I _ - :FINAL APPROVAL ( V
i
HOME OWNER-1311ILDER DIA LARAIION 1 NO.OF'l:XI51 ING BUILDINGS
I r
I I ON LOT AND USE
I hereby affirm that I and cunlpt from the Contractor's License --- -- —
Law for the following reason (Section 7031.5. l3usinesp and
Professions Code):): NO.PARKING
El 1. as owner ill'
PROVIDED
l' the,property. "ill d(, the 1%, -1, alltl the - -- ---�-- --- - -'•---'---- -
structure is not intended or ul'lercd I'm sale (tieclion Itl•)•I. PROPOSED USE OF BUILDINGI & elm- a, hi- Mgt
I Business and I rofessions ('ode). I br�"'�-
i CONSI'RUCTION LENDING A(il:NCY
1 hereby al'11rnl that there is it cunslruction lendinp aeenl•t 1,411-
tile performance of the work for which this permit'is issued - --------
I (Sec. 3097.Civ.C.). I PROPOSED MAX.OCC.
Lender's Name ( APPLICA^r 1,I(MINI) I ) TEL NO.
I x �.Il i t•�. 1111�. ti/s
Lender's Address ADDRESS li
I certify that I have read this application and stile this the
above information is correct. I agree to Comply with all County PERMIT FEE
I ordinances and Slate laws relating to building ennsiruclim.;Ind
hereby authorize tives of this C'nunly to enlerl upon ISSUANCE FEE I
the above-mention d operty Rlr inspection purposes.
TOTAL FEE
J V
/� I SEE REVERSE FOR EXPLANATORY LANGUAGE
i Si aturc of Pcnniucc Del(I 4
1 WORKERS'COMPENSATION DECLARATION S /6M444 MISCELLANEOUS APPLICATION
1 20-0063DPW12/90 rl ••
I hereby'affirm that I have.a certificate bf consent to self COUNTY OF LOS- BUILDING.AND SAFETY DIVISION
Ylhsure6 or a certificate of:Wdrkers'Compensation Insurance,or
;a certified copy thereof(Set 3800,Lab.C.) 1 - `
i Policy No. Company FOR APPLICANT TO FILL IN BUILDING
^. •�• BUILDING ADDRESS iADDRESS
Certified copy.is:hereby; d X furnished. 9665 1. 2 LAS TUNAS DRIVE LOCALITY
Certified copy is filed'with the county building inspection CITY zip
I department TEMPLE CITY CA 91780 NEAREST,
I CROSS ST.
Date ' Applicant I SIZE OF LOT NO.OF BLOGS.NOW ON LOT DISTRICT NO. I GROUP TYPE PROCESSED BY
CERTIFICATE OF-EXEMPTION FROM WORKERS' 2,748 1 CONST. o.
TRACTBLOCK LOT NOV
COMPENSATION INSURANCE .6561 MAP - HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL..
(This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL
by the permit is for one hundred dollars ($100) or less.) _ g5g7 020 016 USE ZONE SPECIAL CONDITIONS ]
i t�
I.certify that in the performance.of the work for which)chis erlEer TEL No•
I permit is issued'(•shall not employ'any person in any manner CHANG SUN SHIN1(626)445-758C i
so as to become subject to the Workers' Compensation Laws. ADDRESS480 WALNUT AVE. I OCCUPANCY GROUP '
I Date Applicant . CITYl�► _
NOTICE TO APPLICANT: If; after making this Certificate ARCADIA ZIP CA 91007
OCCUPANT LOAD
of Exemption, you should become subject to the Workers' APPLICATION,FOR
Compensation provisions of the-(:tabor Code,you must forthwith EXIT HARDWARE:
comply with such provisions or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑
revoked. No Spec.Know). ❑
'
'
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION C$ Panic Devices ❑
'
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW)
I 9(commencing with Section 7000)of Division 3 of the Busi'rtess :y NO.OF EXITS
and Professions Code,and my license is in full force and effect. ., ame o Business KELLYMUSIK STUDIO �
PARKING• REQ'D DPROVIDED
License Number Lie Class SPACES
I I Contractor Date i LIMITED TIME USE
! I
❑ I am exempt from the licensing requirements as I am a DATE DATE
' licensed architect or a registered FROM: TO:
gi professional engineer
acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S
and Professions Code). IXISTING 13LDG.A-pprx. 1,000 S ft STORIES -7-(:77 SIGN TURF.
Lit or Reg.No. •- Date PRESENT USE OF BUILDING FINAL APPROVAL
i HOME OWNER-BUILDER DECLARATION NO.OFEXISTING 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): I NO.PARCES PRov1DED
i ❑ 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). I
PROVIDING, PRIVATE MUSIC LESSONS
I 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
(Sea 3097,Civ.C.). PROPOSED MAX.OCG
Lender's Name APPLICANT(FRWT) TEL NO.
KELLY KAUNG HUA CHEN (626)378•=777
Lender's Address ADDRESS
I certify that I have read this application and state that the 2426 LENTA LANE ARC IA CA 91006
above information is correct. I agree to comply with all County PERMIT FEE
ordinances and State laws relating to building construction,and
hereby authorize representatives.of this County to enter upon ISSUANCE FEE
the aboy mentioned property for inspection purposes. , --•
s. 1
TOTAL FEE .•
% /0 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signafffre of Permittee Date i )