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HomeMy Public PortalAbout10229 LOWER AZUSA RD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS 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. C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING nn ADDRESS ❑ Certified copy is hereby furnished. ADDRESS ©apt LDLJI5.� LOCALITY ❑ Certified copy is filed with the county building inspection NEAREST department. I OCALITY e.Y, Ie GIT CROSS ST. Date Applicant N AREST DISTRICT NO. OUP TYPE P O ESSED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NO, (CIRCLE)Y STATE AJOR SECOND LOCAL d NO. OF BLDGS. ��'0 (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE FCIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this O permit is issued, I shall not employ any person in any manner NERS S I 1-- so as to become subject to the Workers' Compensation Laws. MAI OCCUPANCY GROUP I I W DRESS L P i/ ,+-. R49. I a- Date.Applicant NOTICE TO APPLICANT: If, after making this Certificate of�. CITY �� C. 7 NOL Ste- Q OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE IJGEOLOGY 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" .. SPACES REO'D E:= PROVIDED D License Number Lic. Class LIMITED TIME USE Contractor Date GATE DATE FROM: TO: I am exempt from the licensing requirements as I am a 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). FINAL APPROVAL ESENT USE OF BUILDING � vi ��^",�g.. � �P 0_""p" Lic.or Reg.No. Date PAJ:rFu NO. OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION ON LOT AND USE I hereby affirm that, I am exempt from the Contractor's z 2 7, A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING \ SPACES PROVIDED # O o 10"6 88 ❑ I, as owner of the property, will do the work and the ' structure is not .intended or offered for sale (Section 0 0 0 0 0 0 0 2 7044, Business and Professions Code). , I . I OPOSED USE OF BUILDING , I , , cv 1r 04) ,016. 18-8'4 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency C_OV 4✓44 nJ� 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, TOTAL FEE and hereby authorize representatives of t County to enter upon th above-mentioned ropert for n pectioon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per (teeo Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) M ISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent 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.). fl Policy No. Company FOR APPLICANT TO FI LL IN ABUILDING DDRESS Certified copy is hereby furnished. LDING ( �• ADDRESS ��� �.-�}Cl.�r'i�C. �Z/�R.s�'L- LOCALITY Certified copy is filed with the county building inspection I q CALITY � NEARE �� ST department. �� L.� �fl fi, 4 l-7ro CROSS sT. Date Applicant NEAREST DISTRICT NO. GROUP TYPE CESSED BY CROSS ST. ,i -OIL 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 ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE /,J!�„(� 17 SIZE OF LOT EXISTING BLDG. G`' I certify that in the performance of the work for which this >67- permit is issued, I shall not employ any person in any manner OWNERrJf, y so as to become subject to the Workers' Compensation Laws. MAIL ] ��.�! OCCUPANCY GROUP 01- ADDRESS ADDRESS /i3 � % 'l:� /I��jt' f I.�- �f�1 Z CD Date Applicant C_� NOTICE TO APPLICANT: If, after making this Certificate of CITY r, [�`� rT,o� S��Z��� OCCUPANT LOAD a_ 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 ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. p 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 REQ'D ,y��,- SPACES PROVIDED License Number Lic. Class I 1 i� e "�Q 6`� < 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 INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGN TURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg. No. Date ............ HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS V 1 ON LOT AND USE / I hereby affirm that I am exempt from the Contractor's ,, L E C*l0— 010 F /Z 11. License Law for the following reason (Section 7031.5, Busi - _ ... i i"Ti i L ness and Professions Code): NO, PARKING a ` 1 AM 3,:'26.. DI, 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 TforI hereby affirm that there is a construction lending agency S11,-t., L 1.2-,5 At• /kj�CT- for the performance of the work for which this permit is issued(Sec. 3097,Civ. C.). R.,��C Lender's Name PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE L 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 y upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Perm ttee 151te WORKERS'COMPENSATION DECLARATION 7E 8754(2_$01 '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.) Policy No. Company FOR APPLICANT.•TO FILL IN BUILDING ADDRESS Q r ❑ Certified copy is hereby furnished. Boo REss c 0 4o�J v LOCALITY El Certified copy is filed with the county building inspection 1,00 NEAREST department. Lo ALITY CROSS ST. Date Applicant 00 EAREST DISTRICT NO. GRO ITYPE PROCE ED BY CROSS ST. i' CONST. CERTIFICATE'OF EXEMPTION FROM WORKERS' LEGALoe!l COMPENSATION INSURANCE DEscRlPnory LOT NO. BLOCK MAP /.0 „ISR gy y, NO. / (CIRCLE) SYATE MAJOR SECOND LOCAL d NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE rIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE OF S;!.;E 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 , S G SL' I— so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP I I W ADDRESS o• .1q Ik0w J�' d' I d Date Applicant C 9Cn L. TE NOTICE TO APPLICANT: If, after making this Certificate of CITY /e Cit rvo. S72 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 deemed revoked. ❑ ❑ No Spec. Knowl. ❑ y 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. �ffeCt. REO'D SPACES PROVIDED License Number Lic.Class �J _ LIMITED TIME USE Contractor Date DATE DATE ,❑ I am exempt from the licensing requirements as I am a FROM: TO: 1 SRE T�R'S licensed architect or a registered- professional engineer slzE OF No. of �'4 acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IGN A000'T.0 RE mess and Professions Code). RESENT USE of BUILDING FINAL APPROVAL � � - I Lic.or Reg.No. Date r- z .0 0 0 0 0 o I c�4) TK o. . , ,Z HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS O a 2 3—84 ON LOT AND USE I hereby affirm that, I am exempt from the Contractor's dF License Law for the following reason (Section 7031.5, Busi- ` ! �a ness and Professions Code): NO. PARKING SPACES PROVIDED ElI, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OPOSED 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.). e 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 upo the above-mention roperty for inspec,06n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION �1 CE 875 r I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION lull insure,.or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec.3800,Lab.C.). Policy No: CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS �/ �• Certified copy is hereby furnished. BUILDING O Wr Ik A_ - LOCALITY L/, ADDRESS rj/G a��It ', V 0 Certified copy is filed with the county building inspection LOCALITY /!( NEAREST department. / l) CROSS ST. Date Applicant NEAREST DISTRICT NO. 1 TYPE RO S5 D Y CROSS ST. K✓�J CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ZI COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STAT MAJOR SE CON 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.) USE of d I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG._ o permit is issued, I shall not employ ny person in any manner OWNER V rj3 ��je}1 IJ y so as to beco e subject to the W r ers' C ensation Laws. MAIL �I,[ OCCUPANCY GROUP o ADDRESS O W�� N�l� �� Date a Applicant _ i LO TEL (� OCCUPANT LO D NOTICE O APPLICANT: If, of m g this Certificate of CITY No. cn Exemption, you should become s 'ect to the Workers' z Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDW .AR with comply with such provisions oI this permit shall be TRAILER USE GEOLOGY INSPECTION E] No Sp Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION PanIC evices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT [j (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. / L� aN! PARKING SPACES REO'D = PROVIDED License Number Lic. Class ;/ LIMITED TIME USE Contractor Date / DATE DATE FROM: TO: I am exempt from the licensing requjrements as I am a licensed architect or a registered pfofessional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity`(Section 7051, Bus- EXISTING BLDG. STORIES SIG SIGNATUREE iness and Professions Code). 'C FI AL APPROVAL Lic.or Reg.No. Date PRESENT USE OF BUILDING �C L / "W-1/ HOME OWNER-BUILpER DECLARATION NO. OF EXISTING BUILDINGS d j ON LOT AND USE - I hereby affirm that I a eC3 exempt from the Contractor's License Law for the foll ing reason (Section 7031.5, Busi- { qe _ _ t ,-iqn ness and Professions Co ): NO. PARKING LU - ❑ SPACES PROVIDED :AMz-n - n.� j I, as owner of t31e property, will do the work and the ,!0U-6 y I t structure is nq4 intended or offered for sale (Section 7044,BusiZRUCTION and Professions Code). CO LENDING AGENCY PROPOSED USE OF BUILDING �F I hereby aff' m that there is a construction lending agency �Q for the pe ormance of the work for which this permit is issued(Se . 3097,Civ.C.). Lender's anile ` n� ' PROPOSED MAX. OCC. \Q` Lend 's Address S� PERMIT FEE `V I C tify that I have read this application and state that the a ve information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hergbq authorize representatives of this County to enter TOTAL. FEE upon t e allove m ti ed property for inspect on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE O igna&A Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(2-80) M I SC E LL^ N E®U S A O 1 LICAT I®N I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAF'E'TY 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. BUILDING .Ioaaq 1v0&1/4e(SA LOCALITY ADDRESS S�GL ❑ Certified copy is filed with the county building inspection ` NEAREST department. LOCALITY CROSS ST. Date Applicant NEAREST /JJ��,(/ [ate DISTRIC NO. OUP TYPE PRO ESSED BY CROSS ST. �T {��i,v Q/ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION LOT NO. BLOCK MAP HIGHWAY } COMPENSATION INSURANCE No. (CIRCLE) STATE MAJOR SECOND LOCAL a NO:OF BLOGS. (This section need not be completed if the work'involved TRACT NOW ON LOT USE ZONE FIAL CONDITIONS Q by the permit is for one hundred dollars ($100) or-less.) usE of /)� J 'SIZE'OF LOT EXISTING BLDG. V� / Ir I certify that in the performance of the work for which this / Q permit is issued, I shall not employ any person.in any Manner OWNER �j�(!�g f QG7�� C. so as to become subject to the Workers' Compensation'Laws. '- /�]MAIL J/�- � OCCUPANCY GROUP LU U A D D R ESS . JC62,� YlY 14 �yy�� �- •Date Applicant 4~1 �� �a NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL. OCCUPANT LOAD Z 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 No Spec. Know]. ❑ 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 ❑ 91(cr'mmencing with Section 7000) of'Division 3 of.the Busi- ness and Professions Code, and my license-,is in full force and fPARKING efect. . `' ' SPACES REq'D PROVIDED L+cvse Number - Lic. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ❑ I am I:kempt from the licensing requirements as 1 am a. licensed architect or a registered professional engineer SIZE OF NO. OF IN CTOR acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iRCSS and Pi'OfeS510IIS Code). ESENT USE OF BUILDING FINAL APPROVAL Lic,or Reg.No. Date (f v DSS /G� 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 ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section z 7468 6 A 7044, Business and Professions Code). OPOSED USE OF BUILDING #'O 0 0 0 88 CONSTRUCTION LENDING AGENCY �G/v 7r1� 0 0 0 0 0 0 0 2 I hereby affirm*that there is a construction lending agency GLV , for the performance of the work for which this permit is �, '8—8 2 issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT' FEE d Q 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 �` �Q � � 4 . and hereby authorize representatives of this County to enter upon the abov •mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signatt a of Permittee Date WORKERS' CUMYBMiAl tuts llCl LAKAl 1VLV20-0063DPW'2/90 d 'L I hereby affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING;AND SAFETY DIVISION insure, or a certificateof.Workers' Compensation Insurance, or a certified copy thereof (Seca 3800, Lab. C.)" Policy No. Company FOR APPLICANT TO FILL IN BUILDING _i '- -"- ❑ - ADDRESS ADDRES �ZUSCertified copy.is hereby:furnished. AIIe LOCALITY ❑ Certified copy is filed with the county building inspection CITYzIP department. (gyp �� Ci ,l',,,0 NEAREST CROSS ST. Date Applicant SIZE OF LO C.. NO. BLOGS.NOW ON LOT DISTRICT NO. GROUP CTYPEONST. PROCESSED BY CL CERTIFICATE OF'EXEMPTION FROM WORKERS' TRACT 4 , 1 LOT NO. O I COMPENSATION INSURANCE MAP - HIGHWAY V NO. (CIRCLE) STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARC ELusE ZONE SPECIAL CONDITIONS I=by the permit is for one hundred dollars ($100) or less.) `.J I.certify that in the performance,of the work for which this Terfy erg TEL NO. F— permit is issued.I shall not employ any person in any manner S t Neo ���� a so as to become subject to the Workers' Compensation Laws. ADDRESS 1303 i �sPn f�V� j OCCUPANCY GROUP Z Date Applicant . CITY ZIP NOTICE TO APPLICANT: If, after making this Certificate C1Card2V1A �D 4-7 of Exemption, you should become subject to the Workers' APPLICATION FOR OCCUPANT LOAD Compensation provisions of theLaborCode,you must forthwith EXIT HARDWARE: comply with such provisions OC this permit shalt be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[ Panic Devices ❑ I hereby affirm that I aril licensed under provisions of Chapter SAFETY PERMIT O (LIST ITEMS BELOW) 9(commencing with Section 7000)of Division 3 of the Business NO.OF EXIT$ and Professions Code.and my license is in full force and effecr. .. ame ot Busluess License Number LIC. CIaSS PARKING• REQ'D PROVIDED ❑� 1 SPACES II��JJ ��JJ j FQ�i! CAUY15t,1 vl SPur1.i1 C_S 0, Contractor Date r iA LIMITED TIME USE l�(�U��� l-f w S ri V) DATE - DATE El am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer acting in my professional capacity (Section 7051, Business SIZEEXISOFBLDG.BLDG. 5 OR ES INS SPECTORG , and Professions Code). Lic. or Reg. No. Date PRESENT USE of BUILDING FINAL APPROVAL 02 HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS , ON LOT AND USE I I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): - NO.PARKING i21 SPACES PROVIDED 1 ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044,Y PROPOSED USE OF BUILDING Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). PROPOSED MAX.OCC. Lender's Name APPLINT) TEL NO: �0o Lender's Address ADDRESS �h (076-3 - I certify that I have read this application and state that the U - A Ttf- le Ct , c4k a('7 qD above Information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize re.presentatives.of this County to enter upon ISSUANCE FEE " the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Cy-nature of Permittee Date 11`UkhL:RS'CUMI'LNSAIION DECLARATION E 875 (11-84)4 CMISCELLANEOUS APPLICATION CE 87t I hereby affirm that 1 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.). BUILDING Policy No.-__-__._('ompany_— FOR APPLICANT TO FILL IN ADDRESS �pG i '"/p Certified copy is hereby furnished. ADBUILDING CgLITY �z!� xx DRESS O•'}� l� �',_ O7 ezzl�_ Certified copy is filed with the county building inspection LOCALITY NEAREST department. $y. +�,, CROSS ST. I)atc–__________/1pp11c:1mt__— NEAREST DISTRICT NOITYPEryGRy�UP i D !/O SEED V CROSS ST. � '�—�� /� CONST, Z� CER 111 1CAlE OF EXEb1 P"f10N FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP RIC Rw Av RD. IC'.C LE) STATE MAJOR SECOND LOCAL _ NO. OF BLDGS. (This CeC(I/m need not lie com ple ted If the N'OCk involved TRACT NOW ON LOT US ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE SIZE OF LOT EXISTINGTI BLDG, O} I certify that in the performance of the work for which this prrnit is issued, I shall not employ any person in any mannckX OWNER of building D L F�– c� so as to become subject to the Workers' Conipensalion 1_1ws' MAIL (J OCCUPANCY GROUP C)ADDRESS L� Applicant TEL. OCCUPANT LOAD NOTICE f0 APPLICANT: If, after making this Certificate of CITU No. v-i Eseniption, 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 sliall be TRAILER USE I] GEOLOGY INSPECTION E] No Spec. Knowl. F] (ICCII1Cd revoked. I('I:NSI•:U('ON"fRACTO RS UECLAKA"PION OCCUPANCY INSPECTION E] Panic Devices 1 hereby affirm that I alit licensed under provisions of Chapter SAFETY PERMIT I] 'LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS mess and PrIfeSSi0oS Code, and my license is in full force a efri(�Xfect. Nam of business PARKING SPACES REO•D D PROVIDED D License Number _ - - . .-- _-- I.ic. ( lass 2/� LIMITED TIME USE Contr:ICh,r .- ..__.. - —._._- Dille__—___ / DATE DATE P.D.: TO: I ani exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer SIZE OF —TNT of INSPECTOR'S acting in my professional capacity (Section 7051, Bus- iness and Professions(.'ode). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg. No. -...---------_._.__-- -- Date HOME OWNFR-13111LDER DECLAR_A_T /�_ ION NO. OF EXISTING BUILDINGS /v `\ / - 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 ElI, 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). PROPOSED USE OF BUILDING ('ONS(RU('I(UN 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,('iv. U.). co .+I Lender's Name _. _._.__--_-_-._ _._....-- _.__-- •_ PROPOSED MAX. OCG. Lender's Address _ . .- – - ---------..--_—_-- PERMIT FEE 1 celtifv ilial I have read This application and slate that the 00 above information is correct. I agree to comply with all County ISSUANCE FEE s ordinances and State I;ms relating to building construction, and herelly authorize representatives of this County to enter TOTAL FEE 25 .00 npolthe above-mentiln •d property for inspection purposes. SI%1:: REVERSE FOR EXPLANATORY LANGUAGE „'Ul:ni �tS CO„PLNSATIONDECLARATION CE 875 (11841 MISCELLANEOUS APPLICATION CE 875 1 hereby affirm that 1 have a certificate of consent tsett COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION utsure, or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab.C.). EUILDING Policy No. Company FOR APPLICANT TO FILL IN ADDRESS ✓•_%r.��J r�/C�L/ G Certified copy is hereby furnished. BUILDING /1� j�,�, nip ADDRESS LJ CA LITY XX Certified Copy is tiled with the county building inspection LOCALITY•�' (� ,/ NEAREST department. xy �_ CROSS CT. Date_ __.—Applicant NEAREST DISTRICT NO. GROUP TII YPE �.y CESS ED BY CROSS 57. �q)� CO-S;� j� (TR 111ICATE OF EXEMPTION FROM WORKERS' (/ LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK Av n1.—AY 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 liv the nermil is fur one hundred dollars (SI00) or less.) USE I :e"I1f1 that 111 tl1C performance of the work for Which 'this SIZE OF LOT EXISTING BLDG. ?"- C_ Permit is issued, I shall not employ any person in any manneX OWNER Of bu11G)Ina �lV SCG SE's EKI sII ;Is to bec�ontr sullied tU the '+Yorkers Compensation Laws. MAIL OCCUPANCY GROUP C= Date Applic�lfilADDRESS IUZZ_ Com- (,Du `-k_ uS� `'`-t C NOTICE TAPPLICANT: r , OCCUPANT LOAD u NOTICE APPLICANT: If, alter making this Certificate of CITY` \� � � NoO.. v; 1:.Cerilption, you should- becnme subject to the Workers' Contnensalion provisions of the Labor Code, you must forth- APPLICATI N FOR EXIT HARDWARE: %%ith comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION O deemed rc+'oked. - EOSLj No Spec. Knowl. jU� I I(TNSL1)C ON'I RAC10RS DECLARATION OCCUPANCY INSPECTION Panic Devices U I 1lcreb\ ai-l;rni that I aril licensed under provisions of Chapter SAFETY PERMIT'[] (LIST ITEMS BELOW) 9 (cnnrinencirig with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Cnde, and my license is in full force an x ( Name Or business PARKING SPACES REQ D U PROVIDED 1 I Lic. Class i r-eS LLQ - - LIMITED TIME USE Dale DATE DP rE ❑ - m I FROM: TO: I am m exept froelle licensing requirements as 1 am a license(! architect or a registered professional engineer NO. OF INSPECTORS acting in Iny processional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE SIZE OF in-ss and Professions Co(10. i PRESENT USE Or BUILDING FINAL APPROVAL 11011E OWN!R-10:11_DER DECLARA TION NO. OF EXISTING BUILDINGS V n'/� r iON LOT AND USE o 1 I herchy affirm that I :u) exempt from the Contractor's 4 /a License I.:Iw for (he iollo+win-, re:Ison (Section 7031.5, Busi- 111 rtes$ and Prnfesslons Code): I NO. PARKING I SPACES PROVIDED 17 1, as owner of the property, will do t)1e work and the structure is not intended or offered for sale (Section. 7044, Business and Professions Code). CONSTRUC I"IDN LENDING AGENCY f PROPOSED USE or BUILDING I ifcrebw affirm that there is a construction lendine agency S for the performance of the work for which this permit is '• .� ::4.,, issued (Sec. 3097,Civ.C.). Lender's Name-------------__..--- _ PROPOSED MAX. OCC. I-enders Address PERMIT FEE25 . 00 .. `"F1 I certify That I hawe read this application and state that the above infor cation is correct. I agree to comply with all County ISSUANCE FEE T! ordinances and State laws relating to building_construction, and hereby authorize representatives of this County to enter TOTAL FEE 25 . 00 =:,: :A upon lite ahuve-mentioned ProPCrty Cor inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE SCY, X;{ ,. „'OKI:ERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I be , o affirm that 1 have a 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.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING it AD REBS Certified copy is hereby furnished. BUILDING 0 y _ CxxADDRESS OCA LITYCertified copy is filed with the county building inspection NEAREST \ LOCALITY f� department. j[y, ' �• CR099 ST. Date _Applicant NEAREST D19 TRICyGRpUP TYPE P ESSED By CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OFSLOGS. (Chis 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 IEXISTING BLDG. >_I certify that in the performance of the work for which t)yis� �)— C-3 permit is issued, I shall not employ any person in any manne3CX,;OWNER of building so as to hecumc subject to the Workers' Compensation Laws MAIL 'CCUPANCY GROUP ADDRESS C Date_ Applicant_ _ NOTICE TO APPLICANT: If, after making this Certificate of CITY No OCCUPANT LOAD v� F-%enlption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth ❑ with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. OCCUPANCY INSPECTION ElPanic Devices ❑ LICENSED CONTRACTORS DECLARATION 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 Bus No, OF EXITSLi Hess and Professions Code, and my license is in full force an ernX CES JJe,. Name of business PARKIN(' REQ'D I PROVIDED SPA11�� License Number Lie. Class A[� LIMITED TIMe'-USE''''''' ('onlractur-- —_-- Date / 1 DATE El1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engineersaE of NO. OF M INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE inessand Professions Code)' PRESENT USE OF BUILDING FINAL APP OVAL Lic.or Reg. No.___—_— _ Date �a� ? IIO<•IE O,VNP:K-RlI1LDER DECLARATION NO. OF EXISTING BUILDINGS y� D I hereby affirm that I :un exempt from the Contractor's ON LOT AND USE License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING El1, 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). PROPOSED USK OF BUILDING ('ONSTRUC'IION 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.CA. Lender's Name PROPOSED MAX. OCC. Lender's Address.._.___------.----------- -- ` PERMIT FEE I certify Ihat I have read this application and stale 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, and hereby authorize representatives of this County to enter y TOTAL FEE 25-00 I J upon tiled al r e tinneproperty for inspection purposes. SEL' REVERSE FOR EXPLANATORY LANGUAGE Xx- (St, XX