Loading...
HomeMy Public PortalAbout10213 LOWER AZUSA RD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) � ���������®�� ���������®� I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS Certified copy is hereby furnished. )--.L-INGtJ 2 ADDRESS ' OCA LITY `' Certified copy is filed with the county building inspection OCALITY `g�iVLC �Y I NEAREST department. l CROSS ST. Date Applicant NEAREST DISTRICT NO. G OUP TYPE PROCESSED BY CROSS ST. ��`O (/ CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 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 ZONESPEC IAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. 2 I certify that in the performance of the work for which this �gg ',�y o permit is issued, I shall not employ any person in any manner OWNER �V �V l C L c� so as to become subject to the Workers' Compensation Laws. MAIL ,Jr /�N �/L) ppm( {� OCCUPANCY GROUP ADDRESS ',V'�l3 �(�� (r-T�`/�/ 1t.t! Date Applicant c�Q� LO g �`9� U•� TEL. V`v —J�1 60 OCCUPANT LOAD Q_ NOTICE TO APPLICANT: If, after making this Certificate of clry No. U J I Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ 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 O PROVIDED License Number Lic. Class LIMITED TIME USE _r 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 INSPECTORS �. acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIESSIG TURE iness and Professions Code). FINAL. APPROVAL � PRESENT USE OF BUILDING Lic.or Reg.No. Date Yf ` 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 -•- I, as owner of the property, will do the work and the SPACES PROVIDED I O I� ;[•7K structure is not intended or offered for sale (Section 1 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 PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon the ove-mentpio�ned p perty for inspection urpo SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76M444 n� ��������p��p p� ���j�n� /j� ��®�p CE 875 (11-84) M N U I� u G`i� N I hereby affirm that I have a certificate of consent to self COUNTY ®F 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 3y1�� C U J ADDRESS G _ Certified copy is hereby furnished. ADDRESSG ( _ �2_0 PL LOCALITY G DCertified copy is filed with the county building inspection LOCALITY 'TE-K r G( NEAREST department. I CROSS ST. Date Applicant NEAREST //,�I}� q DISTRICT NO. JZUP TYPE CESSED BY CROSS ST. ALPtO N V L lD� �7 CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL JS COMPENSATION INSURANCE DESCRIPTION I LOT 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 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 Lor EXISTING BLDG. O permit is issued, I shall not employ any person in any manner OWNEROF/3(, 140/11a so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP a o ADDRESS ~' Date Applicant Q 2 s C-5 LLI NOTICE TO APPLICANT: If, after making this Certificate of CITY U7 TN.,X OCCUPANT LOAD Exemption, you should become subject to the Workers' IAPPLICATION 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. Know]. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMITK (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 a/��� D I!—— ��S`1/� effect. �Y PARKING REQ'D PROVIDED SPACES License Number Lic. Class N LIMITED TIME USE Contractor Date DATE DATE 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 URE iness and Professions Code). r PRESENT USE OF BUILDING G�T FINAL APPROVAL Lic.or Reg.No. Date ' C HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ((/���� D O ' CO FEE 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 j, P11 1:42 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 for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE �� I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE O► e upon the above-mentioned property for inspection urposes. / 3 IC7 SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur PermitL® D e WORKERS'COMPENSATION DECLARATION CE 875 (11-84) M �SC E L LA N E®U S d1 P PU C AM N I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a celtificate of Workers'Compensation Insurance,or a certified copy thereof(See. 3800,Lab.C.). +' BUILDING Policy No. Company FOR APPLICANT TO FILL IN / ADDRESS Certified copy is hereby furnished. BUILDING ( �a 3 LBWfr� 2 tel. ADDRESS o LO CA LIT ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST ^ DIST �NO. &G ;� TYPE �r ]PROCESSED BY CROSS ST. ry J CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP (CIRCLE)NO. (CIRCLEE)) HIGHWAY 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 SIZE OF LOT EXISTING BLDG. 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 OWNER �1= 1611;�//y so as to become subject to the Workers' Compensation Laws. MAIL7 ? OCCUPANCY GROUP ADDRESS 102' 7 Ln# A ,.ZDJ V Date Applicant LU L. NOTICE TO APPLICANT: If, after making this Certificate of CITY C/ NO. OCCUPANT LOAD z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- LAJ{-J a APPL CATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. 0 deemed revoked. 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 PARKING effect. '1,9yLL �nt'�� SPACES REQ'D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: 0 I am exempt from the licensing requirements as I am a IN .- licensed architect or a registered professional engineer SIZE OF NO. OF G CTORAS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SiGN uRE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date (J 1l v v HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS O -� 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 PROPOSED USE of BUILDINGX 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 �5� PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE a!`,Q(f upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE a-z3--12- Date iDate WORKERS'COMPENSATION DECLARATION CE 875(11-84) ySC E L LA V EO S A P®U C AT I her�>y affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800„Lab.C.). q 02 Policy No. Company FOR APPLICANT TO FILL IN BUILDING 22 ✓� ADDRESS/0��d Certified co is hereby furnished. �( BUILDING / ® /p copy y ADDRESS 02{ A-�SV{ Q�j•1j Pi{� flit �7 OCA LITY �'eJ Certified copy is filed with the county building inspection LOCALITY NEAREST department. x �»1 �2 _tf / X1,91 CROSS ST. Date Applicant NEAREST DIST T NO. G UP TYPE CESSED BY CROSS ST. ��D 0 CONST. I / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o e/ 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 ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) I I USE OF I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. d C3 permit is issued, I shall not employ any person in any manner )( OWNER CHU_ KS/iVCT Ts2n ® _' so as to become subject to the Workers' Compensation Laws. MAIL C_ OCCUPANCY GROUP o ADDRESS v ve ~ Date Applicant x 4 H�I L`LI NOTICE TO APPLICANT: If, after making this Certificate of CITYC A JW0R'&1 C4.gi311 TNo`'CQIg) DI �Y S OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of,the Labor Code, you must forth- with comply with such provisions Or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. El deemed revoked. ❑ Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING - SPACES REq•D D PROVIDED License Number Lic. Class ^^ LIMITED TIME USE Ac He Date AL cH eaL _vvc, DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer slzE of NO. OF INSPECTOR S acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES; Z SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date (''� . CLASS K"A+ (Atou/ l S . 6m)7-C r o '_ }-a_ CJ 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 usi ness and Professions Code): NO. PARKING ._ n 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 c W5 Fefl M for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon the above-mentioned property for inspection purposes. �- �$ D9 jai jpv SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) M �SC E L LtVC O U S A P P L C A I O N I herebyo afem that i have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec.3800,Lab.C.). J // Policy No. Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING X ADDRESS 1i j• taU 9 LOCALITY ElCertified copy is filed with the county building inspection LOCALITY NEAREST department. Q b CROSS ST. Date Applicant NEAREST DISTRICT NO. G560UP TYPE PROCESSED BY CROSS ST. �1 O _� V CONST. ,/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Da COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. F BLDGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOWOON 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 an o p p y y person in any manner p�� so as to become subject to the Workers' Compensation Laws. OWNER C 1Yn1 � �� OCCUPANCY GROUP �� C:z Date Applicant Ao REss C� �u t�� �,pa o� D '` LI NEL' OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY No. r°i, 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 USEGEOLOGY INSPECTION 1:1deemed revoked. E] ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 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 SPA CES REQ'D PROVIDED License Number Lic. Class l l� LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF OR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI T E iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING +�+. '3 Lic.or Reg.No. Date `V l l ;U—( �!���. : ?I�/97 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS `IC113 N x 1 P °03 ON LOT AND USE - 04, I hereby affirm that I am exempt from the Contractor's �'` wo 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 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 ordinances and State laws relating to building construction, and hereby auhorize representatives of this County to enter TOTAL, FEE upon t e above entione property for inspection purposes. L 1z I X q 14 L SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permitte Date X WORKERS'COMPENSATION DECLARATION CE 875 R� �SC E n n A�p 0 U S A P P�O C A��®�g CE 875 (1 1-84) p�yu L�elm tl�1 L I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insufo, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS .�� Certified copy is hereby furnished. BUILDING x /O� w&` •.�� LOCALIT ADDRESS11 Certified copy is filed with the county building inspection LOCALITYg NEAREST VI department. r C4, 11 Vo CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P CESSED BY CROSS ST.,41);/ ,G 4D Ad CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Joe I COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLD S. (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 Lor EXISTING BLDG. O permit is issued, I shall not employ any person in any manner OWNER 04 Bct;ldj so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP a X Gi� � • ADDRESS n S M Date Applicant w NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL x• OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION E] 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 ❑ 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 /� r effect. Q`M2 "4 3u��il ess PARKING REQ'D PROVIDED SPACES II�=JJ LLQ= License Number Lic. Class dQ /W ei. LIMITED TIME USE Contractor Date t GZ/ IVhn 4110JA0DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer slzE of NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). �Ito �� . PRESENT USE OF BUILDING FINAL APPROVAL ._� Lie.or Reg.No. Date ,I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS //1� CO' FEE p 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 I„ 1st s� )i_i���l s ness and Professions Code): NO. PARKING IY �• �• • - SPACES PROVIDED F1 I, as owner of the property, will do the work and the !L�lj`> structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING x I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the 2 !10 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_ av upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) M �SC E LhiVEO S A P P UC A T�O I hereby affirm that I have a certificate of consent to self COUNTY ®F LOS ANGELES BUILDING AND SAFE'T'Y DIVISION insure, (gr a cyrtifkate of Workers'Compensation•Insurance.,or a certifie&copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING O�/fin ADDRESS ✓✓ Certified copy is hereby furnished. BUILDING IO2/3 �' �jj�� y,�14' CALITY ADDRESS 'GJ�. �/(,/ Certified copy is filed with the county ilding inspection LOCALITY NEAREST . department. CROSS ST. Date Applicant NEAREST DISTRICT p OUP TYPE CESSED BY CROSS ST. /� / CONST. ERTIFICATE OF EXEMPTION F M WORKERS' LEGAL U((ff COMPENSATION INSU NCE DESCRIPTION LOT NO. BLOCK MAP HIGH AY STATE MAJOR SECOND LOCAL NO. OF BLDGS. NO. (CIRC H) (This sec ' n need not be completed If the work involved TRACT NOW ON LOT USE ZONE SPECIAL CO DITIONS by the per it is for one hundred ollars ($100) or less.) usE SIZE OF LOT EXISTING BLDG.OF I certify that the performance of he work for which this o permit is issued, shall not employ y person in any manner OWNER �Gt(Cpl;nb s� so as to become bject to the Wor ers' Compensation Laws. MAIL OCCUPANCY GROUP o Date plica ADDRESS 1152 S, ;v1QNT-me s , W U �, lt�� ` /"� TEL �(y� p Ji( / OCCUPANT LOA a- NOTICE TO APPLIC T: If, aft r making this Certificate of CITY NO. R{ �O l`i �C�� N Exemption, you shou beco subject to the Workers' Compensation provisions of the abor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such rovi ions or this permit shall be TRAILER USE E] GEOLOGY INSPECTION F] HARDWARE: Spec, Howl. deemed revoked. LICENSED CONTR TORS DECLARATION OCCUPANCY INSPECTION Panic ces D i 1 hereby affirm that I am Ii n ed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Sectio 70 0) of Division 3 of the Busi NO. o EXITS ness and Professions Code, and license is in full force and / �L effect. AME Qt' IUS14e55' PARKING SPACES EQ 1) D PROVID D D License Number Lie. Class GU JM L CEWTM LIMITED TIME USE Contractor Date DATE DA I am exempt fro the licensing re uirements as I am a FROM: TO: licensed archite or a registered ofessional engineer SIZE OF NO. OF INSPECTOR'S acting in my p ofessional capacity ection 7051, Bus- EXISTING BLDG. STORIES SIG &URE iness and Profe ions Code). /r G� FINAL APPROVAL PRESENT USE OF BUILDING G/ Lie.or Reg.No. Date HOME WNER-BUILDER DECLARA ION NO. OF EXISTING BUILDINGS ^� !1 ING �— L ON LOT AND USE V I hereby affir that I am exempt from the Contractor's l/I License Law or the following reason (Section 31.5, Busi- ness and Pro essions Code): NO. PARKING �1 l_i I,`(''t!j 1t._s` J/_(_i.'';= SPACES PROVIDED r,aC. I, as wrier of the property, will do the wo and the _`._r _ )r; ;: struc re is not intended or offered for sale (Section 704 ,Business and Professions Code). CONSTRUCTION LENDING AGENCY Y PROPOSED USE of BUILDING I lie eby affirm that there is a construction lending agency/ for the performance of the work for which this permit is iss ed(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE OV certify that I have read this application and state that the above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .V J , �, Signature of P rmittee Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) M ISCELLANEOUS APPLICATION CE 675 I hereby affirm that I have a certificate of consent to self COU insure, OF LOS ANGELES BUILDING AND SAFETY DIVISION r insure, or a certificate of Workers'Compensation Insurance;or a certified copy thereof(Sec. 3800,Lab.C.). ' "�� BUILDING Policy No. Company FOR APPLICANT TO FILL INS ADDRESS Certified copy is hereby furnished. XX ADDRESS i021 3 Lawer- PA^-!�A (LIQ. 'i ErAPLE (4't LOCALITY " •- FCertified copy is filed with the county building inspection LOCALITY n� NEAREST department. ]�y, ) Ft—`e U? i cexoss sr. Date Applicant NEAREST DISTRICT NO. rOUP TYPE PR ESSED BY CROSS ST. _D� CONS G CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAF nlcuw nY no. (CIRCLE) STATE MAJOR SECOND LOCAL NOOF BLDGS. (This section need not be completed if the work involved TRACT NO.W ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. r I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manneXX OWNER of building MQ HSl0G PLG so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS `1�2 Se•_1��� � ` 1' V Date Applicant w NOTICE TO APPLICANT: If, after making this Certificate of ctrY A(J iptir. 9 F-4, LP11 NOL�$�S��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 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 anix effect. Name of business PARKING SPACES REO'D PROVIDED 11��11 License Number Lic. Class N1C1 61 C_kIL'T__tR L C.E4J LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ElI am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS g P g acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date (� HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND_USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING F] 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 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). `• Lender's Name -- PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the ; above information is correct. 1 agree to comply with all County ISSUANCE FEE :h ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25 . 00 upon the above-mentioned property for inspection purposes. - XX i SEE REVERSE FOR EXPLANATORY LANGUAGE XX SIL - 5 - Signature of Permittee Date -