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Home My Public Portal About9582 LOWER AZUSA RD_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE 875(11 84) MISCELLANEOUS APPLICATION CE 875 I luebaffirm 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 BAD DR WILD]DRDDR4392, 1.dwa Certified copy is hereby furnished UILO ING 91'Y7r) Yj�p LOCALITY Ai .R.. 1if, Certified copy is filed with the county budding inspection 9. CALITYrp 7� NEAREST department �5l♦'tr�..1. el� CROSS ST T , Date Applicant _REST A g` DISTRICT G OUP TYPE PRO 9ED BY ROSS ST �( L6 e I o u.L�+J'.4p ,,,� CONST,/ CERTIFICyATE OF EXEMPTION FROM WORKERS LEGAL. Y COMPENSATION INSURANCE DESCRIPTION Lor No BLOCK MAP HIGHWAY NO (CIRCLE)(This MAJORNO OF SE ND LOCAL (This section need not be completed if the work involved TRACT NOW ON LOTS USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) USE of O I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG V permit is issued, I shall not employ any person in any manner &0 01OWNER (INA&L W&D y so as to become subject to the Workers Compensation Laws A IL � �� OCCUPANCY GROUP FT-i�l Date Applicant o AD RESS S NOTICE TO APPLICANT If, after making this Certificate of ITY L &C No` OCCUPANT LOAD z Exemption, you should become subject to the Workers APPLICA ION 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 and effect PARKING PACES REQ D D PROVIDED D S License Number Lic Class LIMITED TIME USE Contractor Date DATE GATE 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 E (STING BLDG STORIES SI ATURE mess and Professions Code) FINAL APPROVAL Lo PRSENT USE OF BUILDING fSN` Z6& Lic or Reg No Date E HOME OWNER BUILDER DECLARATION No OF-EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractors fi 6 0 9 0 A License Law for the following reason (Section 70315 Busi ness and Professions Code) s vices PROVIDED # 0 S S 088 I as owner of the property will do the work and the S 0 S 0 S S structure is not intended or offered for sale (Section 7044 Business and Professions Code) 1 209-86 CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING v(f� p l�6NLt�� I hereby affirm that there is a construction lending agencyS 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 budding construction and hereby authorize representatives of tips County to enter TOTAL FEE I po=_ u rop y for m ection p rpos p SEE REVERSE FOR EXPLANATORY LANGUAGE _R� i Signature of Permittee a ate 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) P FOR APPLICANT TO FILL IN BUILDING Policy No Com any 7UILDIN ❑ Certified copy Is hereby furnished 60 BUILDING !c LOCALITY ADDRESS , YV ❑ Certified copy is filed with the county building InspectionNEAREST department 80 LOCALITYC1!„r ICROSSST l Date Applicant XAREST DISTRICT NO GROUP TYPE P SSED BY lo CROSS ST CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION Lor No BLOCK MAP �/HIGHWA } No (CIRCLE) STATE MAJOR SECOND LOCAL tl (This section need not be completed if the work involved NO OF LOGS USE ZONE SPECIAL CONDITIONS V P TRACT NOW ON LOT by the permit is for one hundred dollars ($100) or less) USE OF SIZE OF LOT EXISTING BLDG cc I certify that in the performance of the work for which this 0 permit Is issued I shall not employ any person in any manner d offfiNER WaAer Le ffidadlvi Xne - I— so as to become subject to the Workers Compensation Laws OCCUPANCY GROUP W ADDRESS pj leMoaks (f 1 �� r 0' Date Applicant to NOTICE TO APPLICANT If after making this Certificate of r t M TEL g s "J!•2 OCCUPANT LOAD ? Ir 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 LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ 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 Busl ness and Professions Code and my license is In full force and effect PARKING SPACES REO D PROVIDED 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 profgsslonal capacity (Section 7051 BUS EXISTING BLDG STORIES SIGNATURE mess and Professions Code) ESENT USE OF BUILDING ifA X FINAL APPROVAL �•� Lic or Reg No Date •Z HOME OWNER BUILDER DECLARATION NO EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractors a I T License Law for the following reason (Section 7031 5 Busl ness and Professions Code) SP PARKING o M o d!(! SPACES PROVIDED QQ ❑ I as owner of the property will do the work and the • s N5structure is not Intended or offered for sale (Section .s 7044 Business and Professions Code) P.PdVosED USE OF BUILDING �' CONSTRUCTION LENDING AGENCY �I� re� oI(7 I hereby affirm that there is a construction lending agency Rwb v rl 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 this County to enter �S• Q� upon ie above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE --— 6L kf:-�Q Q)I-qd� Sig a ure of Per ittee ate WORKERS COMPENSATION DECLARATION CE 875(2 80) MISCELLANEOUS APPLICATION hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure or a certificate of Workers rs Compensation Insurance or atertified copy thereof(Sec 3800 Lab C) Policy No CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished BUILDING LOCALITY JIV ❑ ADDRESS Certified copy is filed with the county building inspection NEAREST department LOCALITY CROSS ST Date Applicant NEAREST DISTRICT NO GR P TYPE PROCESSED BY CROSS ST1. r, CONS CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL `� ,/y`0 " COMPENSATION INSURANCE DESCRIPTION LOT NO� '1� BLocK NOP MIGMwAT } OlS (CIRCLE) STATE MAJOR SECOND LOCAL a (This section need not be completed If the work involved O oP BLOGs USE zoNr SPECIAL CONDITIONS U P TRACT NOW ON LOT by the permit is for one hundred dollars ($100) or less) USE TI �j ix I certifythat In the SIZE OF LOT EXISTING BLDG f performance of the work for which this Q permit is Issued I shall not employ any person in any manner OWNER U so as toecome subject to the Workers Co pensation Laws MAIL OCCUPANCY GROUPa.11[ ADDRESS 91 xx-*6t � . DateXApplicant �1 QN NOTICE TO APPLICANT after making this Certificate CITY V i n0L 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 deemed revoked ❑ ❑ NO Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ 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 PROVIDED 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 OFNO OF INSPECTOR S acting in my professional capacity (Section 7051 Bus EXISTING BLDG STORIES SI NATURE iness and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL Lic or Reg No Date L) Q HOME OWNER BUILDER DECLARATION NO O EXISTING BUILDINGS ON LOT AND USE \ I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Busi ness and Professions Code) NO PARKING 0 6 0 A 13I as owner of the property will do the work and the SPACES PROVIDED structure is not Intended or offered for sale (Section # • • • • 8 8 7044 Business and Professions Code) 1 PROPOSED USE OF BUILDING I• CONSTRUCTION LENDING AGENCY A • • • • • • I hereby affirm that there is a construction lending agency0805-81 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 ISSUANCE FE above Information LS correct I agree to comply with all County ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter upon the above me tioned property, for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee 0Date WORKERS COMPENSATION DECLARATION CE 875(t 1 84) MISCELLANEOUS A P P L I C AT I O N 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 ADDRESS d Certified copy is hereby furnished """ X LOCALITY ADDRESS ?„ Q �S Certified copy is filed with the county building inspection LOCALITY �� NEAR13ST department 0 c.OSS ST GROUP Date Applicant NEAREST DISTRICT NO TYPE PROCESSED BY CROSS ST L ` CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO OF NO (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOW ON LOTS 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 Q� N(�(diOR5W y so as to become subject to the Workers Compensation LawsMAIL t OCCUPANCY GROUP � 04 Date Applicant ADDRESS x U NOTICE TO APPLICANT If after making this Certificate of CITY NoL� OCCUPANT LOAD H o_ 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 a ❑ ❑ 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 and effect 01CL(S( PARKING REOD PROVIDED SPACES License Number Lic Class 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 SIGNATURE mess and Professions Code) FINAL APPROVAL LIC or Reg No Date PRESENT U56 OF BUILDING .� HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS i �J ON LOT AND US6 1 ,�1 d I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 70315 Busi ness and Professions Code) NO PARKING I as owner of the property will do the work and the SPACES PROVIDED 1529 1 PM12:T structure is not intended or offered for sale (Section 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOM USE OF BUILDING hereby affirm that there is a construction lending agency or the performance of the work for which this permit is sued(Sec 3097 Civ C) ender s Name PROPOSED MAX OCC ender s Address &Vcertify that I have r d t Is pphcation and state that the PERMIT FEE bOve informs on is rrec I ee to comply with all County ISSUANCE FEE rdmances Stat la r9fating to building construction d hereby thorizf represgmtatives of this County to enter TOTAL.FEE s, ori po t e-Tnen o d operty for mspectio purpos s SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date I WORKERS COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C A T I O N I hereby affirm that I have a certificate of consent tself CE 875(11 84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 4 insure or a certificate of Workers Compensation Insurance or LS P� a certified copy thereof(Sec 3800 Lab C 1 OD Policy No Company FOR APPLICANT TO FILL IN BUILDING S ADDRES Certified copy is hereby furnished BUILDING a` /n,f,j�� Q�� LOCALITY ADDRESS Q2 Jf/Wl- 4 { 1 Certifieddepartcopy is filed with the county building inspection LOCALITY ent Temple City NEAREST 10, Date Applicant NEAREST DISTRICT NO GR P TYP p CESSED BY + CROSS ST CONS I CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSLRaNCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO OF BLOCS No (CIRCLE) STATE MAJOR SECOND LOCAL (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 (S 100) or less) USE OF SIZE OF LOT EXISTING BLDG I certify that in the performance of the «ork for which chis nn permit is issued I shall not emplo,. any person in any manner owNER H ok(444/j LQ so as to become subject to the Workers Compensation Laws OCCUPANCY GROUP [;�E] MAILL ` /\I•V ^ ��T (=Date Applicant ADDRESS [( 3 J C i TE NOTICE TO APPLICANT If after making this Certific..te of X CITY S N 0YABNEL NOL OCCUPANT LOAD — Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code I ou must forth } with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec Knowl Z deemed revoked. N LICENSED CONTRACTORS DECLAR4TION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chanter SAFETY PERMIT (LIST ITEMS BELOW) I 9 (commencing with Section 7000) of Division 3 or the Busi- No OF EXITS C4 ness and Professions Code and my license is in full force and effect PARKING REO D CJ PROVIDED C- t y SPACES o r I License Number Lic Class LIMITED TIME USE LL y Contractor Date OATE DATE W V3- I am exempt from the licensing requirements as I arra a FROM TO INSPECTOR S m } licensed architect oI a registered professional engineer SIZE OR NO OF SIG ATURE Z acting in my professional capacin (Section 7051 Bus EXISTING BLDG STORIES m mess and Professions Code) O PRESENT USE OF BUILDING FINAL A�PROVAL Lic or Reg No Date o )0 ;1-40 " � I i HOME OWNER BLILDER DECL4RATION NO OF EXISTING BUILDINGS 1 ON LOT AND USE I hereby affirm that I am exempt from the Contractor s Q p_ I I License Law for the following reason (Section 70315 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 I I 7044 Business and Professions Code) I CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency I I for the performance of the work for which this permit is issued(Sec 3097 Civ C) .. Lender s Name ,pp PROPOSED MAX OCC 1 Lender s Address I ( I certify that I have read this application and state that the PERMIT FEE 25.00 0 above information is correct I agree to comply with all County ISSUANCE FEE ''` i'1 ordinances and State laws relating to building construction and hereby authorize representa es of this County to enter TOTAL FEE I—'' ( I I upon the abo me coned pro f utsgection purposes. 25.00 30 SEE REVERSE FOR EXPLANATORY LANGUAGE r-ta O i lure of Pe itee Date co I i WORKERS COMPENSATION DECLARATION 70M444 20 OO6dUPW 12/90 MISCELLANEOUS APPLICATION I I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Ii t —unsure,or a certificate of Workers Compensation Insurdnce,or a certified copy thereof(Sec 3800 Lab C) 42 Policy No _ Company FOR APPLICANT TO FILL IN BUILDING �� B ILDING ADDRESS ADDRESS I ® Certified copy is hereby furnished X $S z z LOCALITY Certified copy is filed with the county building Inspection cITT ZIP p department )?_.yt�� G14 gl7d D CROSS ST Date Applicant I SIZE OF LO NO OF BLDGS NOW ON LOT DIST` j pion GR TYPE OCESSED BY + CERTIFICATE OF EXEMPTION FROM WORKERS U CONST �I COMPENSATION INSURANCE TRACT BLOCK LOT NO MAP HIGHWAY L) i No (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL uSE PONE SPECIAL CONDITIONS ' by the permit Is for one hundred dollars ($100) or less.) 1 certify that in the performance of the work for which thi OWNERt"i TEL NO t I permit is issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Law DRE O OCCUPANCY GROUPEK] I Date Applicant CITY ZIP NOTICE TO APPLICANT If after making this Certifica JQ3D OCCUPANT LOAD of Exemption you should become subject to the Workers APPLICATION FOR Compensation provisions of the Labor Code you must forthwith EXIT HARDWARE I comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑ I revoked i LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices ❑ 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) a 9(commencing with Section 7000)of Division 3 of the Business NO OF EXITS and Professions Code and my license is In full force and effect PARKING REO D � PROVIDED D I License Number — Lic Class ___ � SPADES Contractor Date LIMITED TIME USE i ❑ I am exempt from the licensing requirements as 1 am a FROM DATE To DATE licensed architect or a registered professional engineer acting in my professional capacity(Section 7051 Business SIZEXISTIN NO OF INSPECTOR s E and Professions Code) NG BLDG STORIES SIGNATURE Lic or Reg. No Date _ PRESENT USE OF BUILDING FINAL APPROVA HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS '/Jy,/'y/J ON LOT AND USE V W I hereby affirm that 1 am exempt from the Contractor s License Law for the following reason (Section 70315 Business and Professions Code) NO PARKING I 1 as owner of the property well do the work and the SPACES PROVIDED structure is not intended or offered for sale(Section 7044PROPOSED USE OF BUILDING I Business and Professions Code) I CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued I (Sec 3097 Civ C) PROPOSED MAX OCC '� ',—"�ty Lender s Name APPLICANT(PAINT) TEL NO ,xj_rt h. C:, Lender s Address ADDRESS I I certify that 1 have read this application and state that the above information is correct I agree to comply with all County PERMIT FEE "`` i p�yl I ordinances and State laws relating to building construction and hereby authorize representatives of this County to enter upon ISSUANCE FEE the above mentioned property for inspection purposes. l ` TOTAL FEE �^+. d SEE REVERSE FOR EXPLANATORY LANGUAGE I Slgnat re or Pernitee Date _!� WORKLRS (OMPENSAIION DL( LARAIION ;)"itI,,,,,, MISCELLANEOUS APPLICATION I hereb\ affirm that I hi\L 1 LCltlliLtlL Ill 1111%L1)1 10 %L11 (OLIN I N 01 1 OS ANGI I I S IWILDIN6 AND SAI ETY DIVISION Insure or a L.erttl lcatt of Workers (unlpL.m it Insm it it or 1 certified cop) thereof (See 1800 1 lh ( ) 111 Pohc) No (011111111% FOR APPLICANT TO FILL 114 BUILDING Z BUILD) G ADDRESS ^ �(e ADDRESS J 3 �1 Certified copy 1% Ili lurnl,hLd ysIJ�a �I _ — LOCALITY f H (ertlfled cop\ 1s Bled nllh tht,,ountn hulldinf,ill pLL1101 ch�� zea Q� NEAREST department ` caosS ST Date APPIIL Illi SIZE OF L NO OF BLE GS NOW ON LOT DISTRICT NO I GR UP TYPE PROCESSED BY CONST I ( ['Rill R All OI EXI MI'IION I ROM \bORkl PTRACT _ OCK LOT NO- (OMI'LNSAII()N INSURANCI MAi T'HWAV t No CIRCLE STATE MAJOR SECOND LOCAL (This set lion nLed not he 4_01111PICIed If IIIL nork In\Ul\Ld ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS t b) the permit is for onL. hundred dull its fti14)01 or It%%1 I LLrlll) ill 11 In IIIL plrlor111111LL 111 IIIL \Lottk 111 ")lith this OWNER TEL NO I _ PLrmtt is issued I sit Ill not Lnlplo) 111) Pu%on ill Ill) ill 111110 L so 1% to become subject to the Workers (onlPul 111011 I Inti ADDRESS OCCUPANCY GROUP 1 Date APPIIL tilt CITY ZIP NOTICE TO A 1111 IC AN 1 II IIIL) ill iklilL Ilu% ( trill it UL OCCUPANT LOAD of Exi mptlon \ou should heunn, %ubli tt to IIIL \\ul kt.1% APPLICATION FOH Compensation pro\lslonsof the Llbor(o(It )011 must 1 a1JlutillI EXIT HARDWARE i compl) with suchpro%ibions lir till" PLnim %)Lill Ili. LILLIIILII TRAILER L15LEl GEOLOGY INSPECTION LI No Spec Known revoked �7 f �1 OCCUPANCY INSPECTIONN Panic Devices IJ LICENSI D CONTRAC)ORS DI( I AR\II(1N ii--�� _ hereb) affirm that I un hLensed undLr p1 o%i%ions of C I il)tLr SAFETY PERMIT O 1LIST ITEMS BELOW) i a 9(commencing with Section 7000)of Dn Islon 1 of U1L Business L NO OF EXITS and Professions(odL old in) IICli14e I%ill lull lorLe old LIILLt MAW C"' - IIIc Sof PARKING REQ D � PROVIDED I I )cense Numhlr I IL ( I 1s% � � ��— 1 - -- — --- -� SPACES I I c Ol,tr Mor I)IIL LIMITED TIME USE - DATE DATE 1 1 till ex#11lpt from file IILen%ing re-quirL1nuil% Is I till 1 FROM TO z licensed architect or I regl%ILred profL%vum 11 Ln1.lnLLr - acting 111 111) profL%%10111I lap ILII) 1titdwn 711%0 lltis1111%% SIZE OF NO OF INSPECTOR S "I and PrulLssunn(Udo) EX IS rING dl SIGNATURE UG — SrORIE S _ - Lie or Reg No D lIL PRESENT USE OF BUILDING � -��' FINAL APPROVAL 1 I IIOML OWNI R 111111 IN It IN ( I AR AIION NO Or L XISiING BUILDINGS - - - — I I ON LOT AND USE hereb) i firm till[ I lilt LSLnlpl )runt [fit (ontrlLtol s l ILLII%L - Law for the following relson ISL_Ltlon 70111 Bu%nlL.s Ind Professions(Inde) NO PARKING El SPACES PROVIDED Is ount.r of IhL proliLlt\ "111 dl IIIL II Ill, Ili l Iht — - - - ---- slrulturL I% not IntendLd or ul1LILd 111 111E ISL01011 /1141 PROPOSED USE OF BUILDING Business Ind Professions Code) i CONSTRUCTION 1 ENDING AGI N( It hlrlby Mont Ill E1 thut 1% 1 ums1111111011 Iu1dInL llun 11111 - — - ---- - - ¢ flee plrfonnutLa. of till "ot1, for "h1Lh Ihl% pLtnul 1% 1%%utd i 1 (SeL 1097 Ctv ( ) I PROPOSED MAX OCC Lenders Name APPLICANT IPkl!r ADDT LNq Lender s Addro s% I k Ln �a��{,[� � I certlly that 1 h IVL re Id 1111% appliL 111011 and st 11L Ulu IhL 7S a, k g 1 7 above Inform Itlon is Lorrelt I agrLe to Lonlpl) "lilt Ill( iunt) PERMIT FEE I ordinances and State laws relating to building constr11L11on ind hereby authorize representa11\es of till% Count) to Lnto upon ISSUANCE FEE the above mentioned proplrt) for nl%llLL11o11 purlit"IL% TOTAL FEE X v �3 fl SI [ RI \'CRSL FOR LXPI ANATORY LANGU\GF i Ign cure of Pernuucc D ut . i WORKERS COMPENSATION DECLARATION 20Ct,S30FVYIXso MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent % self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION (- Insure,or a certh icate of Workers Compensation incur. cc or a certified copy thereof(Sec. 3800 Lab C) Policy No Company FOR APPLICANT TO FILL IN ADDRESS 2 4wAA BUILDING ADDRESS //�� ❑ Certified copy is hereby furnished g2 LONi� /d (.t.S CeL LOCALITY ❑ departmentrtfied copy is filed with the county building Imp ction CITY' �e n ZIP Qr NEAREST �W� A tt,SA R 1 'e lit WING O CROSS ST I Date Applicant SIZE OF LOT NO OF SLOGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY CONST 1 CERTIFICATE OF EXEMPTION FROM WORKER- TRACT BLOCK LOT NO COMPENSATION INSURANCE NOP ((CIRCLZI STATE MAJOR SECOND LOCAL (This section need not be completed if the %%ork Int I%ed ASSESSOR MAP BOOK PAGE PARCEL USEZONE SPECIAL CONDITIONS bt the permit is for one hundred dollars (S 100) or 'ess 1 I certify that in the performance of the %%ork for xhich this OWNER Susi C� TEL No ' permit Is Issued 1 shall not emplo% am person in am m inner Property Z, -W-3022 r so as to become subject to the Rorkers Comp-nsation I aas ADDRESS S�Z W us o, OCCUPANCY GROUP I Date Applicant CITY_ zip w 17 n r I NOTICE TO APPLICANT If after makine this Certlricate �(J OCCUPANT LOAD of Exemption %ou should b-come subject to the bio kers APPLI ATION FOR EXIT HARDWARE Compensatior protislons of the Labor Code .ou must fortnuith Comph ujth such pro%jsions or this permit shall be ae,ned TRAILER USE GEOLOGY INSPECTION❑ No Spec Knowl ❑ ' r-%o1.ed LICENSED CO\TR-ACTORS DECL y ATION OCCUPANC. INSPECTIONtt- Panic Devices ❑ I her-b% affirm that I am li^en.-d and^r pro%Isions of Ch.pte SAFETY PERMIT J (LIST ITEMS BELOW, 1 9(commencing uith Section 7000)of Di%iston of hL Bu3iness No of Exits IL__JI t and Professions Code and m. license is in full fort- and e'-CL License Number Lic Cla%, _. ��PARKING REO D � PROVIDED L__J SPACES i : ' Contractor Date LIMITED TIME USE____ DATE DATE ❑ 1 am exempt from the licensin_ requi ements i i am a F4OM To licens-d architect or a re Ister-d professions' en^ireer INSPECTOR S t actin^_ in rin proics ional cap i it% (Section 70,1 BUSII Lss SIZEEXIS OF BLD^a !j D 2 S NO OF / &NATURE and Professions Cod-) sro PRESENT USE OF BUILDING ` FINAL APPROVAL i Li- or Reg. '�o Date i_ ��rg-at ' I HOME OM MER BUILDER DECLAR.ATIO\ No OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor s Llcelise Lax for the following reason (Section 7011) Business and Professions Code) NO PARKING ❑ 1 as owner of the propertt will do the %tor}, and the SPACES PROVIDED structure is not intended or offered for sale(Section 7034X PROPOSED USE OF BUILDING Wete. Business and Professions Code) } CONSTRUCTION LENDING AGENCY I herebx affirm that there is a construction lending agenc% for the performance of the %%or{, for which this permit Is issued (Sec. 3097 CIN C) PROPO ED MAX OCC Lender s Name -_ _ APPLICANT iFRWTI TEL No CHU We Lender Address ADDRES r _ /� 1 certift that 1 have read this application and state that the S` 2 W W.S A "►T T�'!00a above information is correct. I agree to comply wit i all Coun v PERMIT FEE ordinances and State laws relating to building conbtruc,ion and hereby au rile representatives of this County to enter up(r ISSUANCE FEE I the abo ntione p peg) for in, n purposes G/ TOTAL FEE ' X "o 4:2O p SEE REI FRSE FOR EXPLANATORi LANGUAGE Signalfure0or Permittee Dat I WORKERS COMPENSATION DECLARATION 2o'WZDPw12190 M15L*t:. .1..A1NtUU' NVVL..IL.H1 ILJIN I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,of a certificatrr of Workers Compensation Insurance,or a certified cppy-44mof(Sec. 3800 Lab C) OXr Policy Na Company FOR APPLICANT TO FILL IN ADDRESS ® B ILD) G ADgRESS Certified copy is hereby furnished S 2 (�We4 LOCALITY Certified copy is filed with the county building inspection CITY I ZIP p department '�ey,R L( �� O V NEAREST CROSS ST Date Applicant SIZE OF LO NO OF BLDG NOW ON LOT DISTg�T NO GR P TYPE ssED BY CERTIFICATE OF EXEMPTION FROM WORKERS C�f7��f coN COMPENSATION INSURANCE TRACT BLOCK LOT NO MAP NiwlwAr No ICIHCLEI STATE MAJOR SECOND LOCAL ('ibis section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) 1 certify that in the performance of the work for which this OWNER P TELNO permit is issued, 1 shall not employ any person in any manner Pro ert iJ G n y -T.b�- L so as tq become subject to the Workers Compensation Laws ADDRESSX S , �y c OCCUPANCY GROUP P.0 13,Date Applicant Crr `�9wL� ZIP ^NOTICE TO APPLICANT If after making this Certificate &&P., o 3 v OCCUPANT LOAD tof Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl Elrevoked ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT❑ )LIST ITEMS BELOW) 9(commencing with Section 7000)of Division 3 of the Business NO OF EXITS and Professions Code and my license is in full force and effect PARKING REO D O PROVIDED D License Number Lic.Class SPACES Contractor Date LIMITED TIME USE I s DATE DATE ❑ I am exempt from the licensing requirements as 1 am a FROM TO licensed architect or a registered professional engineer acting in my professional capacity(Section 7051 BusinessSIZEOF NO OF INSPECTORRSE and Professions Code) JEXISTING BLDG STORIES Lic or Reg. No. Date PRESENT USE OF BUILDING ` w FINAL APPROVAL _os HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS tTO✓l �� ON LOT AND USE i'I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 70315 Business and Plrofessions Code) NO PARKING El I as owner of the property will do the work and thSPACES PROVIDED �e' structure is not intended or offered for sale(Section 7044 PROPOSED USE OF BUILDING Business and Professions Code) VI OLD R"VW. 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 APPLICANT(PMT) TEL NO Lender s Address ADDRESS I certify that I have read this application and state that the above information is correct. i agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction and hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes �, �yTOTAL FEE $ � \Zo—LS-�� SEE REVERSE FOR EXPLANATORY LANGUAGE Signa r f Permittee Date