HomeMy Public PortalAbout4700 C MILLER DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm etificat 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.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
�f�,�j �i�li vr�iV �ZIGQi•G� —/
ADDRESS
MCertified copy is hereby furnished. BUILDINTG �/7#b A4' I G_ LOCALITY
ADDRESS �
Certified copy 1S filed with the county building inspection LOCALITY CROSS sT.
department. k. 4.1
Date Applicant NEARESTr� DISTRICT NO. GROUP TYPE PROCESSED BY
J
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. C;1_0?D? CONST.LEGAL
COMPENSATION INSURANCE DESCRIPTION I 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 of 'J
SIZE OF LOT EXISTING BLDG.::::::A
,�/
I certify that in the performance of the work for which this v, o
permit is issued,I shall not employ any person in any manner OWNER J k�
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ® o
/
Date ADDRESS a�Applicant LL,
TEL' o_
NOTICE TO APPLICANT: If,after making this Certificate of CITY AJ No. J 0 7Qp 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. fit/ PARKINGREG'O 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 F INSPECTORS
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. �� STORIES SIGNATURE
No. O
iness and Professions Code).
FINAL APPROVAL _ - Q
DING Q F/ G
Lic.or Reg.No. Date PRESENT USE OF BUIL
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS MID 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
SPACES PROVIDED Leyij
EJ I,
�}� i 1 ell j
I, as owner of the property, will do the work and the .3 J
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 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.C.). O n
Lender's Nam e \ V�
PROPOSED MAX. OCC. l
Lender's Address � I
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 I
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 Pernifttee Date
WORKERS'COMPENSATION DFCLARATIOIV ,=CE 875(17-84) MISCELLANEOUS APPLICATION
I hereby affirm that I Have a cert&a e of-consent to self I
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION u
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. CompanyI FOR APPLICANT TO FILL IN BUILDING
i ADDRESS �L
Certified copy is hereby rnished. BUILDING Q
CA LITY
ADDRESS
Certified copy is filed wit the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applica NEAREST ,rC DISTRICT NO. GROUP TYPE ROCESSED BY
CROSS ST. UJ CONST.
CERTIFICATE OF EX PTION FROM WORKERS' LEGAL
COMPENS ON INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MA OR SECOND LOCAL
NO. ICIRCI.e)
NO. OF BLDGS.
(This section need not a completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for o e hundred dollars ($100) or less.) use of
I certify that in the pe ormance of the work for which this SIZE OF LOT EXISTING BLDG. O
permit is issued,I shall of employ any person in any manner OWNER0PBOU—PAIG ohn eroAfhe)t fin'e e =�
so as to become subie to the Workers' Compensation Laws. MAIL r OCCUPANCY GROUP a
ADDRESS dbl, c�ov,, , EJ �'j�• V
Date A licant
TEL. Y OCCUPANT LOAD n-
NOTICE TO APPLIC NT: If, after making this Certificate of CITY 17j pN No. J �d
Exemption, you sh Id become subject to the Workers' _
Compensation provisi ns of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with ch provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked.
LICENSED NTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that am licensed under provisions of Chapter SAFETY PERMI ❑ LIST ITEMS BELOW)
9 (commencing wit Section 7000) of Division 3 of the Busi NO. OF EXITS
ness and Profession Code,and my license is in full force and
effect. — S PARKING SPACES REq•D PROVIDED
License Number Lic. Classv{{J� /�,f`�/
LJMITED TIME USE
Contractor Date DAT DATE
❑ I am eI'snot
from the licensing requirements as I am a FROM: TO: INSPEC OR•S
licensetect or a registered professional engineer SIZE OF NO. OF
actingprofessional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IGNg • ��
iness andessionsCode). U�� FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg. Date
HONER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby ahat I am exempt from the Contractor's tl;lt j-1 tt]I�j = f'�t]
License Lae following reason (Section 7031.5, Busi-
ness and Prs Code): NO. PARKING %] 0471 1 AM 8:02
I, as of the property, will do the work and the SPACES PROVIDED I
structuot intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING e SS
I hereby affirm that there is a construction lending agency Se %ce Q
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 f Q
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
ordinances and State laws relating to building construction,
and hereby authorize representatives of this ounty to enter TOTAL.FEE U
pon the above-menti d pert for ins tion purp ses.
G q� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perm tee gate
WORKERS'COMPENSATION DECLARATION 76M444 -,11 M I SC E L LA N EO U S APPLICATION
I lureaff that I have a certificate of consent tself CE 875 (11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,, o 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�/
AD DR ESS_T/��/ �✓�L�GPrt, �-�"�
Certified copy is hereby furnished. X _
ADDRESS 1 �-#C3.7ert lecit OCA LIT'
FICertified copy is filed with the county building inspection / LOCALITY NEAREST
department. ^ CROSS ST.
Date Applicant NEAREST DISTRICT NO. I—G—RQU–P TYPE PR ESSED BY
CROSS ST. /f n CONST..
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o (/"( v
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.) usI- 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 mannerx OWNER ro j EyJeJ , ='
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
ADDRESS ` d -e,Date-
PP 'f
NOTICE TO APPLICANT: If, after making this Certificate of CITY _ TELMoi TOL -0 D 7? OCCUPANT LOAD
Exemption, you should become subject to the Workers' I --
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 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. /CWAA49, 0- _.1 PARKING
I SPACES REQ'D D PROVIDED D
License Number Lia T Class ` C I fe E17�Gff �1��+
LIMITED TIME USE
Contractor Date 4 DATE DATE
❑ 1 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
iness and Professions Code). / y ./
Lic.or Reg.No. Date k PRESENT USE OF BUILDING 7fflYa " SyI/I ' FINAL APPROVAL IR-14--lzi
/V
fl CD 2 Cor k o ten' - _ 9 F Pp
HOME OWNER-BUILDER DECLARATION NO. OF EX1 TING BUILDIN S ]
ON LOT AND USE O �y
I hereby affirm that I am exempt from the Contractor's /l•/' ,�1 � �I _ LI0 1 $ fi
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING I_ r i CIMvi
I, as owner of the property, will do the work and the SPACES PROVIDED `I' 1 CII
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING A,Yi ri 0If Ammy
I hereby affirm that there is a construction lending agency Ca-xggrit
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 I TOTAL FEE
upon the above-mentioned property for inspection purposes.
L SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dae
WORKERS'COMPENSATION DECLARATION 'CE 8754(,,-84) 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
f� -��y.�+ ADDRESS
❑ CeItlfled Copy 15 hereby furnished. ADDRE ,A
SS O a !-1jJ� -•' 1 '_.C.
LOCALITY
❑ Certified copy is filed with the count build' 7iL� G-G G�
P Y mg inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTNO GR UP TYPE' LP OCESSED BY
CROSS ST. �� =,(J�� RIC
CONS_CT
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALO� �
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. OF SLOGS. 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
f1j
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 any person in any manner OWNER 04/1W lvRio: C-/V r SP
so as to become subject to the Workers' Compensation Laws. MAIL / �J� OCCUPANCY GROUP a
Date L,' V�4 Applicant ADDRESS /ICER j IR
cs
7/�.4F TEL. l�k _971 3 OCCUPANT LOAD
NOTICE TO APPLICANT: If,after makingthis Certificate of clrY -1' No. i N
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 ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices 0
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi NO. OF EXITS
ness and Professions Code,and my license is in full force and x �7
SPACES
effect. / J PARKING RSQ'D PROVIDED
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
iness and Professions Code). X FINAL APPROVAL J L
PRESENT USE OF BUILDING // /
Lic.or Reg.No. Date v ✓✓✓
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS v/
ON LOT AND USE /// /, NO FEE
I hereby affirm that I am exempt from the Contractor's /0
e
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
El SPACES PROVIDED 1l1'F00-13130 8/25/92
25/�p
I, as owner of the property, will do the work and the CJ3VJ VIJ1 L7/= l L
structure is not intended or offered for sale (Section �iiv a u�'.3
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 correagree to comply with all County ISSUANCE FEE
ordinances and State 1 s relating to building construction,
and hereby autho ' e rese at' es of this County to enter TOTAL FEE
upon the above- en ' e for inspeg purposes.
ZSEE REVERSE FOR EXPLANATORY LANGUAGE
S' n of Ve ittee Date
. W:v��,RS'COMPENSATION DECLARATION 76M444
:F CE 875(11-84) MISCELLANEOUS APPLICATION {�
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION LI
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
Certified copy is hereby furnished. BUILDING /�
ADDRESS 47 eo- AI llet 13a, ` '/ LOCALITY
Certified copy is filed with the county building inspection/,\r LOCALITYNEAREST
department. _/ 1 P,& /P I CROSS ST.
Date Applicant NEAREST DISTRICT NO. [9_IJP
TYPE PROCESSED BY
CROSS GA /S D fi CONST CERTIFIC,ATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. OF SLOGS. 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 SIZE OF LOT EXISTING BLDG.OF
�'•'
I certify that in the performance of the work for which this " � Co
permit is issued, I shall not employ any person in any manner OWNER e0we- ..4�=- ='
so as to become subject to the Workers' Compensation Laws. .. MAIL OCCUPANCY GROUP �� o
Date Applicant ADDRESS EL of o r. he /�ozlo s �• Es
NOTICE TO APPLICANT: If after makingthis Certificate of CITY L, p TEL ,p OCCUPANT LOAD
7 1f �Q No. C�/9
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 b 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 Exlrs
ness and Professions Code,and my license is in full force and [ / r- //
effect. ,[LS ��L �lAJC.� Off�'ViL(� PARKING REQ'D PROVIDED
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
El I am exempt from the licensing requirements as I am a
FROM: TO:
licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING r
Lic.or Reg.No. Date
FEE
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING &dBUILDING
IN s ri ''
ON LOT AND USE U�
I hereby affirm that I am exempt from the Contractor's _
. r
License Law for the following reason (Section 7031.5, Busi �. '� 1 (-�I l_t':
ness and Professions Code): NO. PARKING �/ ' PIN
i(,
0 I, as owner of the property, will do the work and the SPACES PROVIDED - , , s ;N -_
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 S `Luta%ln, Dv ST /'u' /Q r J
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 C
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.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature oflermi tee 15ate
WORKERS'COMPENSATION DECLARATION �E 8;54(11-84) MISCELLANEOUS A P P L I C AT I O N
I hereby affirm 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 u
a certified copy thereof(Sec. 3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FI•LIL IN BUILDING
ADDRESS (t:
Certified copy is hereby furnished. BUILDING 11DO ,L C LOCALITY
ADDRESS
FICertified copy is filed with the county building inspection ' LOCALITY (/ /L Ll NEAREST
department. (Ci/-! (�(� LA CROSS ST.
Date Applicant NEAREST r�} `, /( DISTRICT NO. OUP TYPE PROCESSED BY
CROSS ST. 1V 1/ ( 0 y� G � I 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.) IU
OF
I certify that in the performance of the work for which this slzE of Lor E STING B•D G. o
permit is issued,I shall not employ an person in an manner
P P Y P Y --OWNER Q�
so as to become subject to the Workers' Compensation Laws. MAILA r p OCCUPANCY GROUP
SAADDRESS
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate ofCITY _ TNO.EL.�(� O(O OCCUPANT LOAD
Exemption, you should become subject to the Workers' (CATION FOR k 33 EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth15,2-
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 ❑ (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. / 0-r S1 S PARKING
p SPACES REQ'D D PROVIDED D
License Number Lic. Class L Mid 1`0u
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 SIGT
IN URK
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING ) •)'- qA D _
I
Lic.or Reg.No. Date /f / L
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS L� CI F EiG
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- lei' `}1
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED Pto 1 P11 10,_72
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.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.
upon the abo e-mentioned property for insp ction purposes.
� () SEE REVERSE FOR XPLANATORY LANGUAGE
Signature of Permittee Date!
WORKERS'COMPENSATION DECLARATION CE 875
(11-84) M I SG EL L'A N EO U S 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.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
XX
ADDRESS 4-7,010'� `2L � #C
Certified copy is hereby furnished. BUILDING (�—z� 1 �r C LOCALITY —CEM LTe C-\Z
ADDRESS
Certified copy is filed with the county building inspection LOCALITYNEAREST
department. XX l�i�PL� GROSS sr. LOQE, A�135A
Date Applicant NEAREST `n p� DISTRICT NO. GROUP TYPE P CESSED BY
CROSS ST. LolaLCONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP RIO HWAY STATE MAJOR SECOND LOCAL
No. (CIRCLE)
OF
(This section need not be completed if the work involved TRACT NOW ON LOT BLOGS. USB ZONE SPECIAL CONDITIQNS
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. n —p� c
permit is issued shallnperson in nnev-z Of building
��z=''-y%�'✓ y'
p ,Iot employ Y an Y 1? �maOWNER J
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP
�� �l r- �-'� r-
ADDR ESS�ry? V
Date Applicant , w
L.
NOTICE TO APPLICANT: If,after making this Certificate of CITY NO. OCCUPANT LOAD 7
Exemption, you should become subject to the Workers' —
Compensation provisions of the Labor Code,you must forth- 5/ 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 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 anJX
effect. Name of business PARKING REG'D PROVIDED
� ` SPACES
License Number Lic. Class 11.1 DI IJ CSR l Iv
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 profbssional engineer SIZE OF No.of INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. SroR1Es SI ATURE
inessand Professions Code). �� 8 FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING r 10
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS '� —
ON LOT AND USE V ���
I hereby affirm that I am exempt from the Contractor's ,I u [000—X10 , 6.111•1=Aj
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No. PARKING
.�� 68 35 i
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 cfF x Qr_ 14V—Z KpV
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
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 TOTAL.FEE 25.00
upon the above-mentioned property for inspection purposes.
XX
I SEE REVERSE FOR EXPLANATORY LANGUAGE
M� XX 6 fv
nature I�nnlitec Date
WORKERS'COMPENSATION DECLARATION
CE 875(11-84) MISCELLANEOUS APPLICATION
' CE 875 I I�
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
_n a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN
/
OUILDI 14
ADDRESS
Certified copy is hereby furnished. G
/
ES " ., `k I LOCALITY
FCertified copy is filed with the county building inspection• r7G
department. LOCALITY Temple City NEAREST
CROSS ST,
Date Applicant NEAREST DISTRICT NO. GRO p TYPE P CESSED BY
CROSS ST. ^�% L{• CONST..
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a �/
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK I MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
4NOW
O. OF BLOCS.
' (This section need not be completed if the work involved TRACT ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) SE OF
,SI E OF LOT XISTING 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 NER 3�(-�/J PUPA)
so as 1b become subject to the Workers' Compensation Laws. MAIL i OCCUPANCY GROUP
j I Date Applicant nOREss N. „6Q{,{1dwI 7 4 v-P ,
NOTICE TO APPLICANT: If, after making this Certificate of CITY g7 TEL No`' OCCUPANT LOAD
!��i - i�
Exemption, you should become subject to the Workers' APPLIC ION 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.
I LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONU Panic Devices
` I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi- SAFETY PERMIT ❑ (LIST ITEMS BELOW NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. 04 PARKINGEREq'D = PROVIDED
//� EPA
CS
j License Number Lic. Class — LIMITED TIME USE
Contractor Date DATE DATE
�S
I am exempt from the licensing requirements as I am a FROM: TO.
r) licensed architect or a registered professional engineer SIZE OF NO.OF INSPE CTOR
acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES SI TU E
APPROVAL iness and Professions Code). FINAL APP
PRESENT USE OR BUILDING Z-���
Lic.or Reg.No. Date 4
..tc •r
jU. I—U r __
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 'j
ON LOT AND USE 2
I hereby affirm that 1 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
A�1 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY ROPOSED USE OF BUILDING
I hereby affirm that there is a construction lendCX
ing agency
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name
vj Lender's Address _
PERMIT FEE 25.00 PROPOSED MAX.OCC.
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter I TOTAL FEE 25.00
'•..I I upon the a ove-menti d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION 176M444
;CE 875(11-84) MISCELLANEOUS AO, PLICATION
herebv�affirrr tlhat I have a certificate of consent to self I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
nsure, or'a certificate of Workers'Compensation Insurance,or
I certified copy thereof(Seo.3800,Lab.Q. ' ' '
'olicy.No. Company FOR APPLICANT TO FILL IN BUILDING y7,�
ADDRESS
Certified copy is hereby furnished. Bu1LDING /�/j0 ACL . �.jl& LOCALITY 1-171
ADDRESS (�
Certified copy is filed with the county building inspection I LOCALITY ICL NEARESj 10,
department. 'CC CROSS ST.
Date Applicant NEAREST DISTR/ICT-NO. GRO P TYPE ESSED BY
I CROSS ST. C> D CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION i OT NO. BLOCK MAP HIGHWAY
STATE MAJOR SECOND LOCAL
NO. I
NO. OF BLDGS. (CIRCLE)
;This section need not be completed if the work involved I TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
ay the permit is for one hundred dollars (S100) or less.) USE OF �// }
: certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. 1 o
)erinit is issued,I shall not employ any person in any manner ' owNEi�e" Blgo S /117' �S
;o as to become subject to the Workers' Compensation Laws. _ OCCUPANCY GROUP c
MAIL a
ADDRESS /_ 5 � � �;' O
ll
Date Applicant TEL /' ; uJ
NOTICE TO APPLICANT: If, after making this Certificate of CITYC—L NO. (P OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Zompensation provisions of the Labor Code. you must forth
Nith comply with Such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION No Spec. Knowl. E
Seemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$$ Panic Devices
[ hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) ;
(commencing with Section 7000) of Division 3 of the Busi- i NO. OF EXITS
ness and Professions Code,and my license is in full force and
sffect. r PARKINGi REQ'D PROVIDED
�. SPACES
License Number Lic. Class I
1 LIMITED TIME USE
contractor Date FROM: DATE DATE
I am exempt from the licensing requirements as I am a I
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
R'S
acting in my professional capacity (Section•, 7051, BUS- EXISTING BLDG. STORIES SIG uRE
iness and Professions Code).
I OF BUILDING FINAL APPROVAL
PRESENT USE _
Lic.or Reg.No. Date (
HOME OWNER-BL•ILDER DECLARATION ' NC. OF EXISTING BUILDINGS
hereby affirm that I am exempt from the C oniraCTOI S ( ON LOT AND USE
License Law for the following reason (Section 7031.5. Itusi- IV
ness and Professions Code): NO. PARKING
1. as owner of the propertywill do the work and the SPACES PROVIDED
structure is not attended or offered for sale (Section
7044.Business and Professions Code). p t !
CONSTRUCTION LENDING AGENCY i PROPOSED USE OF BUILDING
hereby affirm that there is a construction lending agency((
'or the performance of the work for which this permit is 11
Lssued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I PERMIT FEE 25.00
f certify that I have read this application and state that the
above information is correct.I agree to comply with all County (ISSUANCE FEE
ardinances and State laws relating to building construction,
iiid herepy authorize representatives of this County to enter I TOTAL FEE 25.00
ipon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
A
Signature of Permittee Date
WORKERS*COMPENSATION DECLARATIONCE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES PUILDING AND SAFETY DIVISION LJ
a certified copy thereof(Sec.3800,Lab.C.).• '
Policy No. Company / FOR APPLICANT TO FILL IN ADDRE9s X706
Certified copy is hereby furnished. X71' BUILD'" �{--700 �1�—�—�� ��, �� � LOCALITY �
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. XX ��MQ C\ CMOs$ ST.
Date —Applicant NEAREST DISTRICT NO. GROUP TYPE P ESSED BY
CROSS ST. ;. r G /� CONSTO
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a •6+
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NOF BLDGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL
(Tills Section need not be completed if the work involved TRACT NOO.W ON LOT USE ZONE SPECIAL CONDITIONS
by lire permit is for one hundred dollars ($100) or less.) use OF
SIZE OF LOT EXISTING BLDG. /
1 certify that !n the performance of the work for which this
permit is issued, I slulll not employ any person in any manneRX' OWNER of building O _tS $ O Te
so as III become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP
ADDRESS 4,16,3 \ �}v'y C
Ei�
Date Applicant S L
NOTICE TO APPLICANT: If, after making this Certificate of 1 CITY QL� OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE-
(
.ompensation 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. ❑
!1('L••NS[•:1)CONTRACTORS DECLARATION
OCCUPANCY INSPECTION❑ Panic Devices
1 hereby affirm that I all( licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
nese and Professions Code, and my license is in full force anix
effect. Name of business PARKING
SPACES REO•D D PROVIDED D
License Number ___-- _— — Lic. Class _ l� C CTe55 �tA TJ � )JC
LIMITED TIME USE
Contractor._---_ _.__ Date DATE DATE
I am exempt from the licensing requirements as I am a PROM: TO:
licensed architect or a registered professional engineerSIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
inessand Professions Code)' PRESENT USE OF BUILDING FINAL APPROVAL i/`��1
Lic.or Reg.No.. ._—__. .—__ __ Date �}GG
HOMEOWNER-131111-DER DECLARATION NO. OF EXISTING BUILDINGS //O
ON LOT AND USE IV'
1 hereby affirm that I aau exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
El [, 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).
r
CONSTRUCTION LENDING AGENCY PROPOSED USK OF BUILDING
1 hereby affirm that there is a construction lending agency
lila the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). I qrw ,=
Lender's Name
PROPOSED MAX.OCC.
Lender's Address
(PERMIT FEE 25 .00 '
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County IISSUANCE FEE
ordinances and State laws relating to building construction, ?:' a
and hereby authorize representatives of this County to enter TOTAL FEE
25.00 -t
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -
- I
XX I XX