HomeMy Public PortalAbout5915-5927 OAK AVE_Miscellaneous__ WORKERS COMPENSATION DECLARATION
CE 875(11 84) M I SC E L LA N EO U S APPLICATION
CE 875
I hereby a cert 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 fy
ADDRES
ElCertified copy is hereby furnished ILDiN6 g f Ii
ADDR 688 A l` LOCALITY
Certified copy Is filed with the county building inspection OCALITY NEAREST
department ig, CR088 ST
Date Applicant NEAREST DISTRIC NO GROUP TYPE P 886D BY
CROSS ST /D �J ^n CONST /�
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY STATIC MAJOR SECOND LOCAL
NO OF BLOGS NO (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT U86 ZONE SPECIAL CONDITIONP
by the permit Is for one hundred dollars ($100) or less) USE of ® 1
I certify that m the performance of the work for which this 8126 OF LOT EXISTING BLDG G v'
permit is Issued I shall not employ any person m any manner ownICR eC.�
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP Q�j� c
Date Applicant ADDRESS `�
NOTICE TO APPLICANT If after making this Certificate of CITYNOL 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
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BICLOw)
9 (commencing with Section 7000)of Division 3 of the Busy NO OF EXITS
ness and Professions Code and my license is in full force and
effect0'0 PARKING RQ D PROVIDED
SRKIN
License Number Lie 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 SIza of No of 0 INSPECTOR a
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL ��rQ�
Lie or Reg No Date PRESENT USE OR BUILDING ` 42!J__
HOME OWNER BUILDER DECLARATION NO OF s iITI BUILDINGS O FEE
ON LOT AND USE
I hereby affirm that I am exempt from the Contractors d
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 $PACKS PROVIDED t� 4496 1 AM 9 3?
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 file 4-'1 fled Lo
for the performance of the work for which this permit is CeAt
Issued(Sec 3097 Cry C) jCa rd-i
Lender s Name
PROPOSICD MAX OCC
Lender s Address PERMIT FEE pA�o0
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 represent es of this County to enter TOTAL FEE �O
upon the abo o p rt r inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
vnature o P imrtts Date
aWORK#RS COMPENSATION DECLARATION
CE 875(11 84) MISCELLANEOUS APPLICATION
CE 875
I hereby affirm that I have a certificate of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
mom or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab CUILDIN)
Policy No Company FOR APPLICANT TO FILL IN BDDR8S6 ". y�
ADDRESS
Certified copy is hereby furnishedLOCALIT
ADDRESS BUILDING
Certified copy is filed with the county building inspection LOCALITY NBARBST
department C.
ST
Date Applicant NEAREST DISTRICT NOj OUP TYPE CESSED BY
CR088 ST � �D�/ CONS
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL a
COMPENSATION INSURANCE DESCRIPTION I LOT NO BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
O OF BLDGS
NO (CIRCLE)
N
(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 or
I certify that in the performance of the work for which this SIZE OF LOT EXISTING SLOG
permit is issued I shall not employ any person in arty manner OWNER ?,&U(`4,0 o
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP c
ADDR68arim
Date Applicant Ld
NOTICE TO APPLICANT If after making this Certificate of CIT NOL OCCUPANT LOAD
Exemption you should become subject to the Workers all AppLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you must forth
with Comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
❑ ❑ No Spec Knowl
deemed revoked
I
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
SAFETY PERMI
9 (commencing with Section 7000)of Division 3 of the Busy NO LIST ITEMS BELOW
NO OP EXITS
ness and Professions Code and my license is m full force and � � �. l� S
effect PARKING REQ D PROVIDED
SPACES
License Number Lic Class LIMITED TIME USE
Contractor Date DATE OATS
I am exempt from the licensing requirements as I am a FROM To
licensed architect or a registered professional engineer SIZE OF No OF INSPECT s
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES SIGN B
mess and Professions Code)
Lic or Reg No Date PRESENT Y8B OF BVILDI FINAL APPROVAL Qom)
HOME OWNER BUILDER DECLARATION No OF EXISTING BUILDINGS
ON LOT AND U86
I hereby affirm that I am exempt from the Contractors Le 0000_0001 3}17/91t
License Law for the following reason (Section 70315 Bun .&0�
ness and Professions Code) NO PARKING -
I as owner of the property will do the work and the SPACES PROVIDED 4't(34 1 PM 12 U1
structure is not intended or offered for sale (Section
7044 Busmeps and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OP BVILDI
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 FE6
above information is correct I agree to comply with all County ISSUANCE FEE
rordmances 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 Permittee Date
WORKERS COMPENSATION DECLARATION cE eie(� 8a) M I SC E L LA N E U S A P P L I C A T I O N
I�hereby affirm cert that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Workers Compensation Insurance or
a certii 4copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING /
ADDRESS
Certified copy is hereby furnished JWILD
INADDRESG 59N-7 f�MPL - X11 / O
LOCALITY
Ceertartiedecopy n filed with the county building inspection ALITY k VE U NEARBBT ir
p CROSS ST
Date Applicant NEAREST DISTRICT NO 1JOUP TYPE CUSSED BY
CROSS ST LAS ' UN AS - -� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCED68CRIPTION LOT NO BLOCK MAP HIGHWAYNo OF STATE MAJOR SECOND LOCAL
No ICIRCL61
(This section need not be completed if the work involved TRACT NOW ON LOTS USB ZONE BPE CIAL 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 A y
so as to become subject to the Workers Compensation Laws [ Jp� OCCUPANCY GROUP OC
MAIL zV •V
Data Applicant ADDRESS
making I G rvi Ory TEL W',a0 Il E��Z I t;
OCCUPANT LOAD d
NOTICE TO APPLICANT If after mak this Certificate of circ No rn
Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE Z
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be ❑ ❑ No Spec Knowl
deemed revoked TRAILER USE GEOLOGY INSPECTION
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 Durston 3 of the Bust NO OF EXITS a
ness and Professions Code,and my license is in full force and PARKING
effect SPACES RBQ D PROVIDED
( 1 04-AL C N iE 2
License Number Lic China LIMITED TIME USE
Contractor Date DATE DATR
F1I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO OF PROM io iNSPB CTOR S
acting m my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL
Lic or Reg No Date PRESENT USB OF BUILDING Of
HOME OWNER BUILDER DECLARATION NO of EXISTING BUILDINGS D
ON LOT AND USB
I hereby affirm that I am exempt from the Contractor s !
License Law for the following reason (Section 70315 Bust /// 00110-OMI 5/2.0/5+t
ness and Professions Code) NO PARKING ':P10 1 GMiI'■S+S
I as owner of the property will do the work and the SPACES PROVIDED h71J7 1 ft�ED42
structure is not intended or offered for sale (Section
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affum 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 n correct I agree to comply with all County ISSUANCE FEB
ordman and State laws relating to building constriction
and here authorize representatives of this County to enter Torwi.FEE
upon the ove men ned p party for inspection firpops
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Jute
WORx tS COMPENSATION DECLARATION
CE 875(11 64) M I SC E LLAN EO U S APPLICATION
..- CE 875
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING D SAFETY DIVISION
insure+ or 'fl
a cap icate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800,Lab C) �— /
Policy No Company FOR APPLICANT TO FILL IN BAUILDING
DDR688
Certified copy n hereby furnishedBDDRsss 5919—B Oak Avenue
LOCALITY
C Iendceco copy is filed with the county building inspection LOCALITY Tele City,CA 91780 CROSS BTAir
P
Date Applicant OJOARIST Las Tunas and Oak Avenue DISTRIgg T N GROUP TYPE 688KD BY
R088 ST �ji 8 CONST 1 l
CERTIFICATE OF EXEMPTION FROM WORKERS LKowL 4 a
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK NOPHIGHWAY
OR BLD68 (CIRCLE) STATE MAJOR SECOND LOCAL
NO
(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) USK of
I certify that m the performance of the work for which this SIZE of EXISTING BLDG C3
permit is Issued I shall not employ any person In any manner O King—Nang Chen C3
y
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP c
Donnas 404 E Las Tunas Dr #205 L. W
Date Applicant
NOTICE TO APPLICANT If after making this Certificate of CITY San Gabriel NO 818-309-1240 OCCUPANT LOAD a
Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE z
Compensation provisions of the Labor Code you must forth
with comply with such provisions oI this permit shall be TRAILER USK[:] 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 Busy No of EXITS
ness and Professions Code and my license is in full force and ,
effect PARKING REp D = PROVID BD
SPACES
License Number Lic Class CNM OSTAL CENTER
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the hcensmg requirements as I am a FROM To
hoensed architect or a registered professional engineer slzK OF No OF elLMINSPECTOR S wruRE
acting m my professional capacity (Section 7051 Bus EXISTING BLDG sroRlEs
mess and Professions Code) FINAL APPROVAL S /�
Llc or Reg No Date RESENT USE OF BUILDING N/A 7
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS 0,331 4/►�ip{�li1
ON LOT AND USK 6,96 1 AM -7�tyf
I hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 70315 Busy
ness and Professions Code) NO PARKING
I as owner of the property will do the work and the SPACES PROVIDED O
structure is not intended or offered for sale (Section
7044 Business and Professions Code) JPW
R 0P086D U86 OBUILDING Retail Stores
CONSTRUCTION LENDING AGENCY n
I hereby affirm that there is a construction lending agency Private Mailing Service
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
Lender s Name
PROPOSED MAX OCC
Lender s Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter TOTAL FEE J?5
upon the above me red roperty fo irlspectro pu oses
r 9 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dat
WORKERS COMPENSATION DECLARATION 75M444 M ISC E LLA N EOU S APPLICATION
rt
I hereby a cethat I have a certificate of consent tself CE 875(11 84)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
Certified copy is hereby furnished BUILDING ' LOCALITY
ADDRESS
Certified copy is filed with the county building inspection OCALITY NEAREST
department CROSS Sr
Date Applicant NEAREST DISTRICT NO6 OUP TYPE P CBSBED BY
CROSS ST O� �J CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL /�
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK NO HIGHWAY(CIRCLE) STATE MAJOR SECOND LOCAL
NO OP BLOGB
(Thu section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit Is for one hundred dollars ($100) or less) _ USE of
I certify that m the performance of the work for which this SI 6 OP LOT EXISTING BLDG c
permit is Issued I shall not employ any person in any manner 6OWNER Mtn—T
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP c
ADORE 88 �� t--�
Date Applicant o k �� ul
G
NOTICE TO APPLICANT If after making this Cerfflcatg of CITY T (,,i No 818 1�t �D0OCCUPANT LOAD
Exemption you should become subject to the Workers IppLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be ❑ ❑ No Spec Knowl
deemed revoked TRAILER Y86 GEOLOGY INSPECTION
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$( 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 Busy No of ExlrB
ness and Professions Code and my license is in full force and ,. /` S S r
effect U-Ir PARKING REG D PROVIDED L 1
J
License Number Lic class Rin SPACES 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 OP INSPECTOR S
acting m my professional capacity (Section 7051 Bus EXISTING BLDG STORIES SIGMA RB
mess and Professions Code) PRESENT Y86 OR BUILDING n/a_ _ 1 FINAL APPROVAL F
Lic or Reg No Date V G �
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS n J �
ON LOT AND USE ("i�/ x4 0001 10/27/C-
I hereby affirm that I am exempt from the Contractors `i11
License Law for the following reason (Section 70315, Bun ,\ ..220 1 FM12C'u
ness and Professions Code) NO PARKING
I as owner of the property will do the work and the SPACES PROVIDED
structure Is not intended or offered for sale (Section
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY IPROPOSICD USE OF BUILDING
I hereby affirm that there n a construction lending agency 40
for the performance of the work for wluch this pernut is
issued(Sec 3097 Civ C)
Lender s Name
PROPOSED MAX OCC
Lender s Address My
PERMIT FEB VV
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
L co
1,
SEE REVERSE FOR EXPLANATORY LANGUAGE
'Aligtura of Permittee Ibati
WORKERS COMPENSATION DECLARATION CE 875(1 1 sa) MISCELLANEOUS APPLICATION
I here affirm that 1 have a certificate of consent tself COUNTY OF LOS ANGELES - PUILDING AND SAFETY DIVISION
insure a certificate of Workers Compensation Insurance e or
a czrtifie copy thereof(Sec 3800 Lab C)
Policy No ti Company , FOR APPLICANT TO FILL IN 9ULDNADDRESS
Certified copy Is hereby furnished BuAVE OAK IS LOCALITY
Certified copy is filed with the county building inspection LOCALITY
NEAREST
department CROSS ST of
Date Applicant NEAREST LAS TUNAS DR DISTRICT NO G OUP TYPE BSSBD BY
CROSS ST �DV CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
No OP BLDGS NO (CIN CLE)
(This section need not be completed if thb work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) USE of
I certify that m the performance of the work for which this size oR Lor EXISTING BLDG
permit is Issued I shall not employ any person in any manner OWNER
so as to become subject to the Workers Compensation Laws MAIL CCUPANCY UP c
Date Applicant ADDRESS qa 5 9 2 OAK AVE S
NOTICE TO APPLICANT If after making this Certificate of clrY NO OCCUPANT LOAD D-
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 USKGEOLOGY INSPECTION ❑
deemed revoked ❑ ❑ No Spec Known
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIO 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 Buse- No OF EXITS
mess and Professions Code,and my license is in full force and effect PARKING It D PROVIDED
SPACES
License Number Lic Class LIMITED TIME USE
Contractor Date DATE OATS
13 I am exempt from the licensing requirements as I am a FROM To
licensed architect or a registered professional engineer size of No of INSP S
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES
SI u
mess and Professions Code) FINAL APPROVAL
Lie or Reg No Date PRESENT USK OR BUILOlN6 �7
HOME OWNER BUILDER DECLARATION No OF EXISTING BUILDINGS O ,�j� 146 FEEI
ON LOT AND USE
I hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 70315 Bust �' 00W—M17 '*/I�q
ness and Professions Code) NO PARKING
riI as owner of the property will do the work and the SPACES PROVIDED *909 1 A111169
structure is not intended or offered for sale (Section
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOS u86 OP BUILDING 1
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
Lender s Name
PROPOSED MAX OCC
Lender s Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter TOTAL.FEE
uponIng=
erty for inspection purposes
SEE REVERSE OR EXPLANATORY LANGUAGE
O3-71-941
Signature of Permittee Date
WORKERS COMPENSATION DECLARATION
CE 875(11 84) MISCELLANEOUS APPLICATION {�
CE 875 LI
I heteby iffam 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 BDDR688UILDING
A
FiCertified copy is hereby furnished BVILDING LOCALITY
ADDR688
DCertified copy is filed with the county building inspection OCALITY NBARBST
department CROSS ST
Date Applicant NEAREST DISTRICT pNO GROUP TYPB CUSSED BY
CRO88 ST �YCONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK NO HIGH WAY STATE MAJOR SECOND LOCAL
"aw
OF HLD68
(This section need not be completed if the work involved TRACTON LOT U86 ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) oP
SIZE OR LOTTI LD6
I certify that in the performance of the work for which this permit is issued I shall not employ any person in airy manner OWNER
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP a c
ADDRESS ~
Date Applicant uvJ
NOTICE TO APPLICANT If after making this Certificate ofCITY No` OCCUPANT LOAD
Exemption you should become subject to the Workers ppLtCATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be TRAILER USE[] 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 Buw NO OF EXITS
ness and Professions Code and my hcense is in full force and
effect PARKING
SPACES ARKIN REQ D PROVIDED
License Number Lic Class Amy
LIMITED TIME USE
Contractor Date DATE DATE
PROM To
I am exempt from the licensing requirements as I am a
licensed architect oI a registered professional engineer SIZE OF NO OR INSPECTOR 8
acting m my professional capacity (Section 7051 Bus EXISTING BLDG BTORICS
919rATURN
mess and Professions Code) FINAL APPROVAL
Lic or Reg No Date RESENT USE OF BUILDING Ae,-,r
HOME OWNER BUILDER DECLARATION No OF EXISTING BUILDINGS
ON LOT AND USE
10
I hereby affirm that I am exempt from the Contractor s (I l 10/20/97
.
License Law for the following reason (Section 70315 Bun i Q�.,1
ness and Professions Code) NO PARKING 2298 1 AM 9:31
ElI as owner of the property will do the work and the SPACES PROVIDED
structure n not intended or offered for We (Section
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED U86 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 t
I certify that I have read this application and state that the PERMIT FEE CV
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 QD
upon the above mentioned prop rty for inspection purposes
�r 0� � SE$REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
WORKERS COMPENSATION DECLARATION 76M4" I N EO U S APPLICATION
CE 976(11 94)
1 hereba .that I have certificate of consent tself COUNTY OF LOS BUILDING AND SAFETY DIVISION
insure or
or a certificate of Workers rs Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C) `
Policy No Company FOR APPLICANT TO FILL IN BUILDINGR ���� e/7
ADD688 �,e
Certified copy n hereby furnished X AD DR B 88 BV ILDING 5
LOCALITY
department copy is filed with the county building inspection LOCALITY Q NSAREST 01
CROSS BT
Date Applicant NEAREST DISTRICT NQ O V TYPE CE88ED BY
CROSS ST J/ V� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL '�/
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK NAP HIGHWAY STATE MAJOR SECOND LOCAL
NO OF BLDGS NO ICIRCLE
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONN 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 o
permit is issued I shall not employ any person in my manner OWNER n %I
so as to become subject to the Workers Compensation Laws OCCUPANCY GROUP ® OZ
MAIL �
Date Applicant ADDRESS C3
` e~.s
NOTICE TO APPLICANT If,after making this Certificate of CITY G TEL
Qjp 3�9�/ p OCCUPANT LOAD H
Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE z
Compensation provisions of the Labor Code you must forth
with comply with such provisions oI this permit shall be TRAILER USEGEOLOGY INSPECTION
deemed revoked ❑ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000)of Division 3 of the Busy SAFETY PERMIT❑ (CTBT!TENS BELOW NO OF EXITS
ness and Professions Code and my license is in full force and //��
effect "? SPACBS REO D = PROVIDED
License Number Lic Class (� ' �� 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 engineer SIZE OF NO of INSPECTOR 8
acting in my professional capacity (Section 7051 Bus EXISTING BLDG STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL
Lic or Reg No Data PRESENT USE OF BUILDING l�
HOME OWNER BUILDER DECLARATION No OF EXISTING p 1`
ON LOT AND USK '�� =_W01 b/ 9/9.I
1 hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 70315 Bust $� 0183 1 PM 12:5b
ness and Professions Code) NO PARKING
I as owner of the property will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency /Q��-� Ste°'?//C 4e!;-
for the performance of the work for which this permit n /" ��/Y! 4 S`�
issued(Sec 3097 Civ C)
Lender s Name
glwPR
PERMIT FEE
Lender s Address 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 TOTAL FEE
upon the above mentioned property for inspection purposes
V x SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
7
WORKERS COMPENSATION DECLARATION CE 87512 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 APPLICANTTO FILL IN BUILDIN !
ADDRB .
❑ Certified copy is hereby furnished UILDING t�h[+ N iLOCALITY
40 ADD-DIN
V/
❑ Certified copy Is filed with the county building inspection NEAREST
department LOCALITY �� / ! CROSS ST
Date Applicant ARBST FFh++ r'a.r DISTRIC NO O OYP TYPE P O SSBD BY
CROSS STLAS OP CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL a
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL d
N OF SLOGS NO (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT USB ZONE SPECIAL CONDITIONS V
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 t
permit is issued I shall not employ any person in any manner BRIER t
so as to become subject to the Workers Compensation Laws ARESS AI / �� ( V OCCUPANCY GROUP a W
N
Date Applicant n
NOTICE TO APPLICANT If after making this Certificate of CITY `/ 4-,0L � ,SSD Z 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� No Spec Knowl
deemed revoked Panic Devices E]LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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 andPARKING
01 effect SPACES RES D PROVIDED
License Number Lic Class
jam LIMITED TIME USE
Contractor Date �/ DATE OAT E
❑ 1 am exempt from the licensing equlrements 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 !O"Q STORIES i SIGNATURE
mesa and Professions Code) r PRESENT USE OF BUILDING Ah X-CFINAL APPROVAL �Z
Lic or Reg No Date LIP 111 449�
HOME OWNER BUILDER DECLARATION No OF EXISTING BUILDINGS
ON LOT AND USE `
I hereby affirm that I am exempt from the Contractors D 0 �
License Law for the following reason (Section 7031 5 Busi Q� �t�}i
Iness and Professions Code) NO PARK
PING ED �u
❑ I as owner of the property will do the work and the ij AM 7-1.
structure is not Intended or offered for sale (Section I /�
7044 Business and Professions Code) �!
PROPOSED U86 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)
Lender a Name PROPOSED MAX OCC
Lender s Address PERMIT FEE IR- 1 O
I certify that I have read this application and state that the ISSUANCE FEE
above Information is correct I agree to comply with all County
ordinances and State laws relating to building construction TOTAL FEE 7`d Q
and hereby authorize representatives of this County to enter
u9w the above me to pr petty for inspection poses SEE REVERSE FOR EXPLANATORY LANGUAGE
OA Pt/ D9-o3-t /
Signatur of Perini tee Date
WORKERS COMPENSATION DECLARATION 7eM444 MISCELLANEOUS A PPLI CATI O N
CE 875(11 84)
I u rebo affirm that I have a certificate of consent to c self , COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a cert>fjcate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
Policy No Compan91120! aMC FOR APPLICANT TO FILL IN ADDRESS ADDR688
Certified copy is hereby furnished OO A BAD DR 688U .92
ILDING LOCALITY
Certified copy is filed with the call ty building inspection LOCALITY �y NNARKST / w^ `�-�,/w�
O� M�L+� V` CROSS ST (A.i , "9
Date • �'Apphcant NEAREST DISTRICT NO GROUP TYPE P C688BD BY
CERTIFICATE OF EXEMPTION FROM WORKERS ceoss BT L.A.S� 1MW0 r D d colvar v
LEGAL O
COMPENSATION INSURANCE ONSCRIPTION LOT NO BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO (CIRCLE)
71.
O OR BLD68
(This section need not be completed if the work involved TRACT `t OW ON LOT I USN ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or low)
USE oP
I certify that m SIZE OF LOT XISTING BLDG the performance of the work for which this �
permit Is Issued I shall not employ any person in any manner OWNER 90 y
so as to become subject to the Workers Compensation Lawsa m
MAIL OCCUPANCY GROUP c
DateApplicant ADDRESS U
NOTICE TO APPLICANT If after making this Certificate of CITY No OCCUPANT LOAD 0-
Exemption, you should become subject to the Workers APPLICATION FOR EXIT HARDWARE z
Compensation provisions of the Labor Code you must forth
with
deemed corempply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAPNTY PERMIT LIST ITEMS BELOW
9 (commencing with Section 7000)of Division 3 of the Busy ❑ NO OF EXITS
ness and Professions Code and my license is in full force and
effect PARKING PROVIDED
���.�� I 1
License Number � SPACES R6q D Lic Class � LIMITED TIME USE
ContractorMIQ TSQA Date �6'•9Z �N1F�v (J�aJ�' Var
DATE DATE
I am exempt from the licensing requirements as I am a FROM TO
licensed architect oI a registered professional engineer SIZE OR No oP INSPECTOR 8
acting in my professional capacity (Section 7051 Bus EXIBTING BLDG I STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL
PR BSKNT U86 OF BUILDING COM
Lic or Reg No Date1-7-31-q?,
HOME OWNER BUILDER DECLARATION No OF EXISTING BUILDINGS 00'�a �-��
ON LOT AND USE vvp
I hereby affirm that I am exempt from the Contractors 1 I
License Law for the following reason (Section 7031 S Bun /y
ness and Professions Code) NO PARKING 'V 0000-CMI "
,70/92
as owner of the property will do the work and the SPACES PROVIDED V 4204 1 FM 2 17
structure is not intended or offered for sale (Section i
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 MW
above information is Correct I agree to Comply with all County ISSUANCE FEE
ordinances and State laws relatmg to building construction
and hereby authorize repress atives of this County to enter TOTAL FEEdb
upon the above m pro rty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signatu of Permittee Date
WORKF.$S COMPENSATION DECLARATION MISCELLANEOUS APPLICATION
. . CE 876(11 84)
I CE 875
hereby affirm that I have a certof consent tself COUNTY OF LOS ANGELES BXDING AND SAFETY DIVISION
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
BUILDING
Policy No Company FOR APPLICANT TO FILL IN ADDRKS
Certified copy is hereby furnished
ADDRESS{7 VILDING /�'
V LOCALITY
Certified�pecopy is filed with the county building inspection OCALITY clgeosa sT
Date Applicant NBARKST //�� � ,,y DISTRICT NO G O TYPE CKSBED By
CR088 ST (�{/G I.�/, / AR—P CONST I
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL (J �/
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO
or BLDOS 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 _a
I certify that in the performance of the work for which this SIZE OF LOT ��� EXISTING BLDG C2
permit is issued I shall not employ any person in any manner wNKR ..� 4 rte'
so as to become subject to the Workers Compensation Laws MAIL qQUP®NCY GROUP �a c
Date Applicant ADDRg88 ��11''
NOTICE TO APPLICANT If after making this Certificate of clry noL -j6 OCCUPANT LOAD
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth APPLI ATION FOR EXIT-HARDWARE
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑
deemed revoked IH' No Spec Known
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Id
Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Er (LIST ITEMS BELOW)
9 (commencing with Section 7000)of Division 3 of the Busy No OF EXITS
ness and Professions Code and my license is in full force and
Effect PARKING REG DPROVIDED
License Number Lic Class SPACES
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 �l No of IN G TOR 8
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG f STORIES SINATURg
mess and Professions Code) FINAL APPROVAL
Lic or Reg No Date
PRESENT V86 OR BUILDING
No F11--hr
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS . D
ON LOT AND USE
I hereby affim that I am exempt from the Contractors B la3
License Law for the following reason (Section 70315 BusiA GOOGl v 4/93
ness and Professions Code) NO PARKING O II JI� '7L'Q 48
F1I as owner of the property will do the work and the SPACES PROVIDED 4 `418
structure is not intended or offered for sale (Section
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USK OF BUILDING
I hereby affnm 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
abqve information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter TOTAL FEE a�
upon the above menti-opedolmperty for inspection purposes
SZEER VERSE FOR EXPLANATORY LANGUAGE
Sngnat f Permittee Da
WORKERS COMPENSATION DECLARATION 76M444 M I SC E LLAN EO U S APPLICATION
CE 875(11 84)
I hereby aff�rni that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Workers Compensation Insurance or
a ceitified copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRB88
Certified copy is hereby furnishedUILDIN6
DDR 68 S LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department CROSS ST
Date Applicant NEAREST DIST N G OUP TYPE CUSSED BY
CROSS ST D� ��� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL �i�
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY
NO (elweLK) STATE MAJOR SECOND LOCAL
No
(This section need not be completed if the work involved TRACT NOWOON LOTS USEZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) USK of
I certify that m the performance of the work for wluch this SIZE OF LOT EXISTING BLDG
permit is issued,I shall not employ any person m any manner OWNER f j!? y
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP y/f� c
Date Applicant ADDRESS LGf W
rsL OCCUPANT LOAD
NOTICE TO APPLICANT If after making this Certificate of CITY �A �No H
Exemption you should become subject to the Workers z
Compensation provisions of the Labor Code you must forth APPLICATION FOR EXIT HARDWARE
with comply with such provisions oI this permit shall be TRAILER USKGEOLOGY INSPECTION ❑
deemed revoked ❑ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000)of Division 3 of the Busy SAFETY PERMIT❑ (LIST ITEMS aULow) NO OF EXITS
ness and Professions Code and my license is m full force and . i
effwRM o-E PARKING REO D PROVIDED
1 1
` LL��JJ
License Number Lic Class SPACES 68 LIMITED TIME USE
Contractor Date DATK 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 INSP crGR s
acting m my professional capacity (Section 7051 Bus EXISTING BLDG STORIES SI rugs
mess and Professions Code) FINAL APPROVAL `
Lic or Reg No Date PR B86NT U86 OF BUILDING
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS &VV f. �'
ON LOT AND US6
rr
I hereby affirm that I am exempt from the Contractors �
License Law for the following reason (Section 70315 Busi t' L
V
ness and Professions Code) NO PARKING 0000--IJ001 , 2 X74
I as owner of the property will do the work and the SPACES PROVIDED 41}J 1 PM12:7
structure is not intended or offered for sale (Section 12:7?
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OP 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 IN
I certify that I have read thus 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 FSE 00
upon the above men(loned pmp rty for inspection pu pose s
{ SEE REVERSE F EXPLANATORY LANGUAGE
S ture of mittee D e
WORKERS COMPENSATION DECLARATION MISCELLANEOUS APPLICATION
o. CE CE 875 876(11 84)
I hereby affirm that I have a certificate of consent tself COUNTY OP 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 ,6?/
27
Certified copy is hereby furnished BUILDING W. Aa aVF: LOCALITY
ADDRBSS •
Certified copy is filed with the county bmldmg spection ILOCALITY0M
NEAREST
departmentCROSS ST
Date Applicant NEAREST w/. NeS DISTRICT NO GROUP TYPE P 6886D BY
CROSS ST U0165 -2 CONST ",
CERTIFICATE OF EXEMPTION FROM W RS Lsawl O' r
COMPENSATION INSURAN DESCRIPTION Lor No BLOCK MAP HIGHWAY
I7�, Ivo (eIRCt.e) STATE JOR SECOND LOCAL
No OF('Phis section need not be completed if work involved TRACT NOW ON LOTS USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred do ($100) or less.) USE or
I certify that in the performance of the ork for which this SIZE OR LOT EXISTING BLDG
permit is issued I shall not employ any erson in any manner OWNER y
so as to become subject to the Worker Compensation Laws IN • OCCUPANCY GROUP
ADDR68 9 Y� c
MAIL `� !J 04K A/�/
Date AppllCSnt • W
NOTICE TO APPLICANT fn
this Certificate of CIr M T-ON 0-40• 0 OCCUPANT LO a-
Exemptton, you should bject to the Workers rn
Compensation provisions oCode APPLICATION FOR EXIT HARDWARE z
you must forth
with comply with such por this permit shall be TRAILER USE❑ GEOLOGY INSPECTION❑ No Spee` InOW1 ❑
deemed revoked
LICENSED CONTRECLARATION OCCUPANCY INSPECTION❑ Panic vices
I hereby affirm that I am her provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW)
9 (commencing with SectioDurston 3 of the Busi- . No P EXITS
Hess and Professions Codense is in full force and
eff� PARKING REQ D PROVIDED
SPACES
License Number Class LIMITED TIME USE
Contractor Date PA4141 RA DATE DATE
I am exempt fro the hcensing requirements as I am a
licensed architect or a registered professional eitg<neer SIZE or No OR PROM To INSPECTOR 8
acting in my pr essional capacity (Section 7051 Bus-
sic
ila- EXISTING BLDG STORIES
SIGNATURE
men and Profe roCode) FINAL APPROVAL
Lic or Reg No Date PRBBENT USB OF BUILDIN ..
HOME O R BUILDER DECLARATIONNo OR EXISTING BUILDINGS FEE
ON LOT AND USE � TJ
I hereby affirm that I am exempt from the Contractors
License Law fo the following reason (Section 70315 Bust 1 $/i�/Q�
ness and Profe 118 Code) NO PARKING
I as o of the property will do the work and the SPACES PROVIDED 4981 i 3:�b
structu is not intended or offered for sale (Section
7044 stress and Professions Code)
NSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby firm that there is a construction lending agency 1 IGi
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
Lender s Name
PROPOSED MAX OCC
Lender s Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above mentioned property for inspection purposes
/( e SEE REVERSE FOR EXPLANATORY LANGUAGE
oor rfJ Signature of Permittee Date
WORKERS COMPENSATION DECLARATION CE 8775((11 84) MISCELLANEOUS`APPLICATION
er—A,,W4 hereby affirm that I have a Certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Workers Compensation Insurance or
a cerhiled copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN Bu1LDINo���� /
woossss
Certified copy is hereby furnished XX wooRsss ,� dQ
CW cwLlrr
Certified copy U filed with the county building inspection LOCALITY NEAREST
department XX CROSS ST
Date Applicant MEANS ST GQS dt Q$ ';STRICT®NO Goa coesr CEsseD Br
CROCERTIFICATE OF EXEMPTION FROM WORKERS LEGAL �o
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK NOP HI e4E) STATE MAJOR SECOND LOCAL
��L NO OF SLOGS
(This section need not be completed If the work involved TRACT NOW ON LOT USK ZONE SPECIAL CONDITIONS
by the permit Is for one hundred dollars ($100) or IIEL) USE of
SIZE OF LOT EXISTING BLDG '
I certify that m the performance of the work for which this
permit is issued,I shall not employ any person In any mannelRX OwNER of buildin ' A
so as to become subject to the Workers Compensation Lawa I - OCCUPANCY GROUP �C c
ADORERS Q �.!
Date- PP
NOTICE TO APPLICANT If,after making this Certificate of CITY , Trio` OCCUPANT LOAD
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code you must fort>r /da APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USE[3 GEOLOGY INSPECTION❑ No Spec Knowl
deemed invoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT[ (LIST ITEMS BELOW)
9 (comencug with Section 7000)of Division 3 of the Busy No OF EXITS
m
ness and Professions Code and my license Is in hill force an*x Name of business PARKING
effect SPACES REG D PROVIDED
License Number LIC Class / reef LIMITED TIME USE
Contractor Date DATE DATE
PED..: TO
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO OF INSPECTOR
SIGNATURE
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES
mess and Professions Code) FINAL APPROVAL
LIc or Reg No Date PRESENT YSE OR BUILDING .�uG
HOME OWNER BUILDER DECLARATION No OF EXISTING BUILDINGS r.ON LOT AND USE `
I hereby affirm that I am exempt from the Contractors �' /
License Law for the following reason (Section 70315 Bust-
and Pn)04
fessions Code) NO PARKING I'
es owner of the property will do the work and the SPACES PROVIDED +
s cture is not intended or offered for sale (Section t
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 ,o
Issued(See 3097 Civ C) �..�
Lender s Name
PROPOSED MAX OCC
Lender s Address & "n
I certify that I have read this application and state that the PERMIT FEE r M
above information is correct I agree to comply with all County ISSUANCE FSE PP7
.
ordinances and State laws relating to building construction, 25 00 ''1
and hereby authorize representatives of this County to enter TOTAL.FEE -n
' upon the ve mentioned property for inspection purposes.
" SEE REVERSE FOR EXPLANATORY LANGUAGE
XX
XX 7� }
Signature of ermlttee ate s _�+
WORKERS COMPENSATION DECLARATION i.� 78M444- MISCELLANEOUS APPLICATION
`
^„ , hereby affirm that I have a certificate of consent tsoli CE 878(11,84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Workers Compensation insurance of
a certified copy thereof(Sac 3800.Lab C) do
Policy No Company FOR APPLICANT TO FILL IN BYILDIN6���
ADOR668
Certified copy n4 hereby furnished Bun.DING fid { cwLrrr
XX ADDRBBB
0 Catl[W copy is filed with the county buffing inspectiondepartment s LOCALITY NEARCPOSST
z
Date Applicant NEAR T LQ,S (rt Q S ISTRICT 0 G our corlsT csssse BYCROSi
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL ��
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK No HIGHWAY
(CIR LEI STATE MAJOR SECOND LOCAL
NO OF BLOOD
(This section need not be completed d the work lnvolved TRACT NOW ON LOT USE XON6 SPECIAL CONDITIONS
by the permit M for one hundred dollars ($100) or less.) USK or
I SIZE OF LOT EXISTING BLDG
I certify that m the performance of the work for which this c
permit is issued,I dhall not employ any lin In any manneRX OWNER of buildin
so as to become subject to the Workers Compensation Laws. MAIL OCCUPANCY GROUP c
ADDRESS p ^ ��
Date ApphcantuJ
NOTICE TO APPLICANT If after making this Certificate of CITY GJe s,e> no OCCUPANT LOAD
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code,you must forth- /4W APPLICATION FOR EXIT HARDWARE
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 DBVIces
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT[3LIST ITEMS BELOW)
st a
9 (commencing with Section 7000)of Division 3 of the BuNo OF EXITS
nese and Professions Code and my hcense Is in full force anx Name of business PARKING
effect SPACES use D PROVIDED
License Number Lic Class
LIMITED TIME USE
Contractor Date OATS DATE
I am exempt from the licensing requirements as I am a PROM Vol
licensed architect or a registered professional engineer SDs OF No OF INSPECTOR s
acting m my professuinal capacity (Section 7051 Bus- EXISTING BLDG STORIES SIGNATURE
mess and Professions Code) Q FINAL APPROVAL
Lic or Reg No Date PRESENT YSs OF BUILDING L
HOME OWNER BUILDER DECLARATION No OP EXISTINO BUILDINGS
o
I hereby affirm that I am exempt from the Contractor s N Lor AND USE [1� .4
License Law for the following reason (Section 70315 Bust If.x„11
and Professions Code) NO PARKING
as owner of the property will do the work and the SPACES PROVIDED
cture is not intended or offered for sale (Section
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY ( PROPOSED YOB OF BUILDING
I hereby affirm that them is a construction lending agency
for the performance of the work for which this pernut is _ z
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 Pse 1-� i-- M
above Information is correct I agree to comply with all County ISSUANCE Pus m
ordinances and State laws relating to buil construction
and hereby authorize representatwes of this County to enter TOTAL.PEE 25.00 -71 4
' upon the a vementioned property for inspection purposes.
i
XX ]CIC " SEE REVERSE FOR EXPLANATORY LANGUAGE r
Signature of ermittee pate -� iv
WORKERS COMPENSATION DECLARATION M ISCELLARE,OU "�►PPLICATION
+► CE
G4111- CE 8875(1784)
75
1 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) t
Policy No (ompany FOR APPLICANT TO FILL IN eu1LDINaa�.7
ADDRESS
1-3 Certified copy is hereby furnished BUILDING ZG LocwLlrr
XX DRESS Y
Certified copy is filed with the county building Inspection LOCALITr Q NEwt1EST
department 3M G' G� _`f D clloss ST
Date Applicant NEAREST DISTRI'T NJoy9u° eons CESSED Br
�
CFRT[I KCROSS ST ATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE DESCRIPTION I OT NO BLOCK NOP `,IRC`U) STATE MAJOR SECOND LOCAL
NO OF
(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 (5100) or less) USE OF
SIZE OF LOT EXISTING BLDG
1 certify that in the performance of the work for which this
C-1
permit is issued I shall not employ any person In any mannetx DWNER of building I-14 LIQ
a+ 9s to become subject to the Workers Compensation Laws MAILOCCUPANCY GROUP
ADDRESS C*MaNe W*L- E�:]
Date— ApplicantuJ
NOTICE TO APPLICANT If after making this Certificate of CITYno7.. OCCUPANT LOAD 13-
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 GEOLOOT INSPECTION❑ No Spec Knowl
deemed revoked
I ICCNSED(ON7 RACTORS DECLARATION OCCUPANCY INSPBCTtON Panic Devices
I hereby affirm that 1 am licensed under provisions of Chapter SAPETY PERMIT[] (LIST ITEMS BELOW) a
No OF Extrs
9 (commencing with Section 7000)of Division 3 of the Busi-
ness
ustness and Professions Code and my license is in full force an Name of business PwwKINa
effect SPACES REO D = PROVIDED
I
(cense Number Lic Class OVb T#41� WMtZJIW4 C A-r
LIMITED TIME USE
(ontrctor Date DATE DATE
PROM TO
1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer 91290" No or 1 SSPEATURE
acting in my professional capacity (Section 70SI Bus- EXISTING BLDG $TOR IRS
iness and Professions Code) FINAL APPROVAL
Lic or Reg No Date PR68ENT YS6 OF BUILDING v
HOME OWNFR BUILDER DECLARATION No OF S
OP EXISTING BUILDINGSI �I g ^
1 hereby affirm that I am exempt from the Contractors ON LOT AND V86 oonn-noo 1 �1_4/1r
I icense 1 aw for the follow Ing resson (Section 7031 S Bust 1893 1 AMO
'1 t�`
ness and Professions Code) No PARKING
1 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)
CONST RUCTION 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 N•ime
PR POSED MAX OOCC
I ender s Address
I certify tint I have read this application and state that the PERMIT FEB
s, above Information is correU I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction 25-00
and hereby authorize representatives of this County to enter TOTAL.PEE
s� upon the above mentioned pro erty for inspection purposes SEE REVERSE FOR XPLANATORY LANGUAGE
XX �• ]CX t6
19mi mirt of I rrnrttic 11 rte
%%ORkLRS COMPENSATION DECLARATION 7SM444 MISCELLANEOUS APPLICATION
* • !�
F WI hereby affirm that i have a certificate of consent to self CE 875(11 84)
msure or a certdicateof Workers Compensation insurance or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION i
a certified copy thereof(Sac 3800 Lab C) t '
Policy No Company FOR APPLICANT TO FILL IN BUILDING �i}`�
woowsss //��✓
Certified copy is hereby furnished XX woowsss ,r Y.SD L�
Loewurr
Certtfled copy u filed with the county buddhig inspection LOCALITY CROSS ST
ST
department JIM t:woss
Date Applic-int NEAREST DISTRI NO GROUP FPS CESseD BY
CROSS ST ` G CONST
(I R 111 i(ATE OF EXEMPTION CROM WORKERS LEGAL 'fid
COMPENSATION INSURANCE OESCRIPTION LOT NO BLOCK NAP IININWAT
No (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work Involved TRACT NOW ON LOTOF S USE ZONE s►e IAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) use OF 91
1 certify that in the performance of the work for which this 9aZE OF LOT EXISTING SLOG
permit is issued I sh-ill not employ any person in any mannekX —En of building
so -1s to bet otne sulletI to the Workers Compensation 1 awe MAIL OCCUPANCY GROUP r,
'
Date_ applicaooae1111 •
applicant A...
NOTICE TO APPLICANT If after making this Certificate of CITY o0
6 TO
OCCUPANT LOAD
I%emption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE
(ompensalion provisions of the Labor Code you most forth
pith comply uith stiLli provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION 0 No Spec Knowl
deemed rccoked
i K I NSE D(ON I RA( TORS DECLARATION oceu►wN¢r INSPECTION Panic Devices
1 IIL rLb) affirm that I am licensed under provisions of Chapter SAFETY PERMIT[3iLIST ITEMS BELOW,
9 (commencing with Section 7000)of Division 3 of the Bust. NO of EXITS
ness -ind Professions Code and my license is in full force a"
*x Name of business PARKING REG D PROVIDED
_ s.Aees
I isunu NumbLr —_-- — — I is Class •ln� tAd
t LIMITED TIME USE
(ontr Ictor _ ___ Date DATE OATS
OM TO
I am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer 1112E OP NO OP INSPECTOR s
acting in my professional capacity (Section 7051 Bus EXISTING BLDG srowlE11 111GNwruwE
loess and 1 rofessiuns(ode) FINAL APPROVAL Z'
1 is or Reg No _— —_ _Date vwssewT Use OF BUILDING tea'
IIOMi OWNCR BUILDER DELI ARATION NO OF EXISTING BUILDINGS
ON LOT AND USE
I htmb). iffirrit that 1 int exempt from the Contractors y fj
I icense I-kw for the folho%Ing reason (Section 70315 Bust
ness Ind Professions Lode) NO PARKING
ri1 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)
(ONS I RUC I ION l ENDING AGENCY PROPOSED use OF BUILDING
I hcreb) affirm that there is a construction lending agency
for the performance of the work for which this permit is 0 Q :t
issued(Sec 3097 Civ C) i
I ender s Name __--
pwo.oseo MAX Dec � 1
I ender s Address
I certify taut I have read this application Ind state that the PERMIT P66
shove information is correLt 1 igree to comply with all County ISSUANCE FEE r
• ordinances and State haus relating to budding construction
-ind hereby authorize representatives of this County to enter TOTAL FEE 25.00
upon thea ve_mentioned property for mspeLtion purposes -
i — - - - — SEE REVERSE FOR EXPLANATORY LANGUAGE
XX � XX `
I WORKERS COMPENSATION DECLARATION _
CE 875(17 841 MISCELLANEOUS APPLICATION
-- —- CE 875
�I I hereby affirm that I have a certificate of nconsentIncur to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Workors Compensation Insurance or
I a certified copy thereof(Sec 3800 Lab C) 992
Policy No Company FOR APPLICANT TO FILL IN aoowass 3
Certified copy is hereby furnishedUopase Z 3 RE mW� LOCALITY
D
t 1 dCertified
ant is filed with the county budding mspectio g LOCALITY L-� 0-j. . R �-D NC:OSS ST
Date /AppluCONST
t NawRHST Dig TQM GR P TYPE EBSED BY
//� 09 1
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST LHGAL
COMPENSATION INSLRANCE DESCRIPTION Lor NO BLOCK NAP NIONWAV
(This
(CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT NOWOONBLOT S USE ZONs SPECIAL CONDITIONS
by the permit is for one hundred dollars (5100) or less) USK of
SIZE OF LOT EXISTING BLDG b.
I certify that m the pertoritiance of the work gLmlany
hich 61
this
permit is issued I shall not employ any person manner OWNERso as to become subject to the%4orkers Compn Laws 1 OCCUPANCY GROUP
NAIL }A
i Date APD11GtnL
=ass o S C Af w G/` L 4U"b
NOTICE TO APPLICANT If atter making this Certificate of CITY I /d 0D9z0 k1P—*(f ^6nW OCCUPANT LOAD =
Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you must torch
I with comply with sulh provisions or this Hermit ,hall be TRAILER USE n LONo Spec Knowl
GEOLOGY INSPECTION ❑
deemed re%oked C
n LICENSED CONTRACTORS DECL AltATION OCCUPANCY INSPECTION LZ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PHRMIT[3 (LIST ITEMS BELOW)
9 (commencing with Section 7000)of Division 3 of the Busi- NO of EXITS
Hess and Professions Code and my license is in cull force and
effect PARKING RBO D PROVIDED
� SPACES II��JJ
X I License Number Lic Class
9 LIMITED TIME USE
is Contractor Date DATE OATS
W
PROM 'O
I am exempt trorn he licensing equirements as I am a
m i licensed architect or a registered orotessional engineer SIZK of ND of INSPECTOR s
SIGNATURE
7 acting in m% prote%uonal =at,u% lSet,tion -0-i I Bus EXISTING BLDG STORIES
mess and ProtessiunsCode) FINAL APPROVAL
v LIC or Reg No Date PRESENT USB OF BUILDING
HOME OWNER BLILDER DECLARATION No OF EXISTING BUILDINGS AL 1/Q � UOU � r1/9
ON LOT AND USE
I herebv affirm that i am exempt from the Contractor s �r � ISI
Lilense Law for the folio%%mg reason iSection 7031 _ Bust
ness and Professions Code) NO PARKING
I as owner of he propertv will do the vork and the SPACES PROVIDED
structure is not intended or otfe ed tut sale i Section
I 1044 Business and Protessions Codel
PROPOSED USE OF BUILDING
n ' CONSTRLCTIOV LENDING AGENCY
I hereb) affirm that there is a construction lenduig agency (Zt V —& -�� -TI, Orth
( for the performance of the work for %hicli this permit is
{ issued(Sec 3097 Civ C)
Lender s Name
PROPOSBO MAX OCC
Lender s Address
25.00
I certify that I have read this application and state that the PERMIT FEE
abol.e mformauon is correct I agree to comply%ith all County ISSUANCE FEH
ordinances and State lads relating to building construction
( d hereby authorize representatives of this County to enter TOTAL FEE 25.00
u on the above mentioned property for inspection purposes
% �`C�- g Z- SEE REVERSE FOR EXPLANATORY LANGUAGE
a
D-tte
Signature of v.m tt
UnRI.CRS CO)IPENIS.ITION DCCL►RMON 76M444 MISCELLANEOUS APPLICATION =�
I CE 875 11 1 841 /-�
I hereby affirm Leri that 1 have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a Lertificate of Workers Compensation Insurance or ,
�1 a certified copy thereof(Sec.3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN loo�ss eJ�v '444e �
Certified lop* u hereby furnished BUILDING rC
a coo DR sss 21 LIAF.• LOCALITY
! Certified copy is fled with the county building inspection g LOCALITY T� NEAREST
department CROSS ST
Date applicant NEAREST OISTRI T rfi I WP lywcasquo BY
CROSS ST
I CERTIFIC GTE OF EXEMPTION FROM%%ORkERS LEGAL O
COMPENSATION INSLRk%CE 265CRIPTION LOT VO BLOCK 4AP HIGMMAr
OF 1116005 NO ICINCL81 STATE MAJOR SECOND LOCAL
NO
(Tills section need not he completed If the work Involved TRACT Now ON Lor US6 Zama SPECIAL CONDITIONS
by the permit Is for lne hundred lollars ISIQQI or lets) I
use of
I ergf% Kiat in he Der urTiant.c it he ,ort or %huh his SIZE OF LOT EYtSTING BLDG
permit is Issued I shall -lot•mplov an% pe on n env manner X owNgR gIhp. C ;dn1
so as to become ublec o the toners Comoe-isatton Laws RAIL OCCLPANCY GROUP
X AOORESS 6b -lipi
Date 1orllt.ant
4267
NOTICE TO APPLIC %%,T If atter mak,n_ his.,e-tilit ate titg CI- JAvo- � OCCUPANT LOAD
Exemption Lou should become subject o the %orkers APPLICATION FOR E(IT HARCwARE
Compensation pro%lsions at he Laoor Code ou -nust forth
i pith lomph lith I h p n%ib Vns r i is e nin hall bo- -RAIL-R JSB 1 GEOLOGY INSPSL-ON X10 Spec Knowl G
deems d re%aked '
' OCCJP4VC INSPECTION rZ Panic Devices
LICENSED 10\TRaCTORS DELL tR%TIO\
01 1 liereb% affirm that I -m licensed under provisions of Lhaoter a
2 I 9 it.otnmencute with Section 70001 of Dnisfon a of he Busi- SAFETY PERMIT = LIST trams 66LOwl NO OF EXITS
ti ness and Professions Code and mV Iltense is in ull orce ind
e►feLt PARKING REG D D PROVIDED
A SPACES
License Numbe L L Ciao% LIMITED TIME USE
a
aCtlntrat.or D1tl DArs DA re
<.qN D
I im a Lnipt rum h% hkensmit euuue nuts % I _i 1 a
m I lit.enxd arLhlteL or 1 exiuer%d -irnie%slonal n_nom_ Izs of vo of INsase-ON
= actin. m "1% orotelslonal .aDaL t bel loll i l BIIC =`CIS- Yo BLZI4 i To C. NATO 6
lneuand P oteuiuns(-odel FINAL APPROVAL ��
•4BSE IT Jse OR SUILDIYa41
3
Li;. or RLL N, _ _ _ D iiL _
= I
HOME OUNER BLILDCR DECL aR%rim Yo OR EXISTINGBUILDINGS 0 AI
ON LOT AND JSE 41'
I hereb% aftlrm hat i Im exempt -nm Ise Cuntrat.tor s
j LiLense Lau for he %llutm_ a-ison bel ton "0-1 Bu%I
ness and Professions t ode) NO PARKING
1 as rnner it he Dropertt till do ht. lora and he PACNS •ROvlD60
struc ure is lot intended or otte Ld it ale SeLnon
i 7044 Bu%iness ind Protesnons l Act v
a PROPOSED J86 OF BUILDING
COh)TRLCTIO\ l LVDI\(, %61\t 1
i I hereb% affirm that here is a lomtruLtion ILnding agent.% n OG Z
1 for the performanLe of the work for whiLh this permit is
issued iSec 309- Gu t i
Lender►Name _
PROPOSED MAX OCC
LLndt.r s \ddress r m
! I Lertifv that I Ita%e read this application and state hat the PERMIT REE 5•
abo%e information is lorrect I agree to Lomph with all Count% ISSUANCE FEE
orduunces and State laws relating to budding construLtfon 3`
ind 1lcrehv authorize representatnes of this Count% to enter TOTAL FEE 25.00 i+
t I upo t ab mentiont.d pm Ertl for inspeLtion purposes Gap.
% ) E SEE REN ERSE COR EXPLANATORY LANGUAGE
c n
WORkERb L01tIPENbAlI0N ULLLAKAIIUN ,DM444 M ISCELLANEO
o t
he>'eba certificate
that I have a certificate of consent tself CE 875(11 84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
PIAGATION
Isere or a certificate of Workers Compensation Insurance or
certified copy thereof(Sec 3800 Lab C)
olicy No Company FOR APPLICANT TO FILL IN BUILDING a�V
ADDRESS
Certified copy is hereby furnishedAoeRass J ezJr ORAA LOCALITY 1
Certifie opy is filed with the count) building mspectio OCALITY 7`— � ,^ NEAR EST
departmentLC ewoss sr
late Applicant NEAREST DISTRIC NO GR P TYPE asset BY
CROSS ST he /j CONST
CERTIFICATE OF EXEMPTION FROM iVORkERS LEGAL v �/
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK No ICIRC AY STATE MAJOR SECOND LOCAL
NO OF BLDGS NO (GIRCLS)
This Section need not be completed if the pork involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
y the permit is for one hundred dollars (SI00) or less.) USE of
I.
certify that in the performance of the wort. for which the SIZE OF LOT EXISTING BLDG ...
ermit is issued I shall not employ any person in any manner OWNER
0 as to become subject to the 1%orkers Compensation Laws MAILv� O OCCU W GRO P
Late ADDRESS Applicant x
40710E TO APPLICANT If after making this Certificate of elTr r/yPtZ- Cl T y NoL gi ao OCCUPANT LOAD
xemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE
ompensation provisions of the Labor Code 'ou must forth ( a
ith comply with such provisions or this permit shall be TRAILER USE O GEOLOGY INSPECTION[] No Spec Knowl
teemed revoked Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
hereby affirm that i am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW)
+ (commencing w ith Section 7000)of Division 3 of the Busy NO OF EXITS
toss and Professions Code and my licence is in full force and
ffectPPACfiB ARKING REO D PROVIDED
S
icense Number Lic Class LIMITED TIME USE
ontractor Date DATE DAYS
I am e%empt from the licensing requirements as I am a FROM TO INSPCC OR S
licensed architect or a registered professional engineer SIZE OFNO OF
acting m my professional Capacitor (Section 70*i1 Bus EXISTING BLDG STORIES slG ..�uR
mess and Professions Cod") .�Qrgg
PRESENT USE OF BUILDING FINAL APPROVAL 7 ry
is or Reg No Date
HOME OI%NER BL ILDER DECL4RATI0^ No OF EXISTINGBUILDINGS g
hereb% affirm that I am exON LOT AND USE exempt from the Contractors E:
tense
�
tense Law for the follon ing reason (Section 7031 a Bust �f��
less and Professions Code) NO PARKING 'r yn
I as owner of the propl.ri) will do thl wort. Ind the SPACES PROVIDED 11
structure is not intended or offered tot salt. (Sttmon
7044 Business and Professions Code)
CONSTRUCTIO\ LE\TD1NC AGE\C1 PROPOSED Use OF BUILDING
herebm affirm that there is a construction lendinL acenci
or the performance of tilt. pork for Much till' pLrmn I%
,sued(Sec 3097 Cn C)
ender s Name
PROPOSED MAX OCC
ender s Address
PERMIT FEE 0
certify that I have read this application and state that the
ibove information is correct I agree to oomph with all County ISSUANCE FEE
Irdmanees and State laws relating to building construction
,Ind hereby authorize representatives of this Countm to enter TOTAL FEE p�j� Cs
Ipgn the above mentioned pro ert}1or inspection purpowb
SLE REVERSL I QR CXPLANATORI LANGUAGE
N ,Signatilie of Permittee Date
i WORKERS COMPENSATION DECLARATION 76M°44 MISCELLANEOUS APPLICATION
I hereby affirm that 1 have a certificate of mor to self CE 875 Ill 841 COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION l
insure or a Le;trficate of Workers Compensation InsuInsuranme or I
P� a cert*tcopy thereof(Sec 3800 Lab C I d901111
OD Polw% No Company FOR APPLICANT TO FILL IN BUILDING
owess r
ao
riCertified copv is hereb% furnished BUILDING 1 Ir Op� eJl� LOCALITY
ADDRESS J 1 /��
I rCertified copv is tiled with the mount,. buddma Inspection LOCALITY Temple Cit eieeoss sT
department P Y
Date Apphmnt NEAREST DISTRICT NO GR P TYP ESSED BY
CROSS ST '�� CONS
i CERTIFICATE OF EXEMPTION FROM %ORKERS LEGAL /E�
COMPENSATION I\SLRA\CE DESCRIPTION I LOT NO BLOCK I MAP HIGHWAY
I No (CIRCLE) STATE MAJOR SECOND LOCAL
NO OR SLOGS
(This section need not he completed if the cork involved -RAC- NOW ON LOT VSE TOMB SPECIAL CONDITIONS
by the permit is for one hundred dollars 4S1001 or legs) USE OF
I SIZE OR LOT EXISTING BLDG ( ti
I certify that in thL ppmrtormanme of she a)ri. u ihfich his =_
permit is issued I Miall not emplos am oe son n an% manner owNER C141A US
so as to become subject to the 1%orkers Compensation Laws OCCUPANCY GROUP
ACC.ESS 0 Ba eo.r8
E;K]
I Date ►pplicant =
NOTICC f() ►PPLIC%NT It at er-nakm_ Iris C.ruit ate tit CITY SAd MMIAP 09 VI/,NOL OCCUPANT LOAD
Exemption sou should become suDiect o thL Unrke s APDLICATICN DOR a-Xr 4ARDINAPE
Compensation proLisions of he Labor erode %ou must forth
I with comon. with such pro%isons Lr bib -+ermit shall be RAILER USE 13 GEOLOGY NSPECTION
deemed Lsoked — No Spec Kyo vl
LKENSCDCONTRACTORS DECLARATION occUPaneY INSPEC"ION Panic Devices
I hereby atfirm hat I am licensed under provisions of Chapter SAFETY PERMIT .^J LIST ITEMS BELOW) a
I 9 1commenLlne with Section "000) of Dntslon o of the Busi• No OF EXITS
ness and P otessions Code and m% license is in full force and
etfemt PARKING REO O PROVID BD ��
N SPCCBS
License \umber L c Class
o LIMITED TIME USE
LL
Contractor Date DATE DA T6
3 l am exempt from the litensma requirements as I am a FgOM TO
I I licensed architect or a registered professional envineer IZE of No oR INSPECTOR s
2 aLtina In 'ni protLs%tonal avaot� $e ion ,a I Bus ERISTING BLDG SORIE SI NATURE
°m FINAL APPROVAL
iness and r' otessicns Code
Q PRESENT USE OF BUILDING Z
G. Lic or Ret; \o Date
x I O
HOME O►1vi R BLILUER DECLAR LTIUh NoOP EXISTING BUILDINGS �0
ON LOT AND USB
I herebv af`irm that I am exempt from the Contramtor s
1 License Law for the following reason i Section -oil a Busi
nets and P otessions Code) No PARKING
I as -)caner of the propert% will do the work and the SPACES PROVIDED
stns ure is not intended or offered for sale (Section I
I 7044 Business and Professions Code)
CONSTRLCTION LENDING AGF\Cl PROPOSED USE OR BUILDING
I hereb% affirm that there is a constriction lendinE laencv 8&ANtr %%
1 for the performance of the work for which this permit is
issued(Sem 3097 Civ C)
Lender s Name
PROPOSED MAX OCC
Lender s Address
I 1 certif) that I have read this application and state that the REKNIT FEE 25.00
above information is morrect I agree to compl) with all County ISSUANCE FEE t'iln
ordinanLes and State laws relating to budding construLtion
and hereby authorize representatives of this County to enter TOTAL FEE 25.00 (�
I upon thL Ibo%L mentiontd pro ty for mspemtion purpose~
r SLC RLVERSC COR EXPLANATORY LANGU►GC
I
Sigitature of Permittee D to
i AOR(.ERS COMPENSATION DECLARATION
CE 875 111 841 M ISCEttANEOUS APPLICATION
CE 875
Afterebiv affirm that I have a certificate of consent to self yi
COUNTY OF LOS ANGELES 13UILD[NG 4WD SAFETY DIVISION
sun or a Lertiticate of Workers Compensation Insurance or
D�;I • a certified copy thereot iSec 3800 Lab C►
og Policy No Compan3 FOR APPLICANT TO FILL IN ADDRESS
�l
ADDRESS or
Certified copv is hereb, furnishedu'LOINGS L] C �• LOCALIT
ADDRESI
1 I
Certified
er rtieed copv a filed with the Lounrt buildine mspectio LOCALITY Temple C�ty q( NEAREST
CROSS ST
Date AppliLant NEAREST DISTRICT N GROUP TYPE P ESSED BY
CROSS ST �•'�� CONS
i CERTIFICATE OF L\EMPTIO\ FROM %ORLERS LEGAL ' .
CO%IPENS AT1ON INSLR k\CL DESCRIPTION LOT NO (BLOCK (MAP NIG C E) STATE MAJOR SECOND LOCAL
I NO IOIRCLCI
NO OF BLOCS
(This section need not be completed if the cork involved "RAC" NOW ON LOT USE LONB SPECIAL CONDITIONS
by the permit is for one hundred dollar, iS1001 or less) USE OF
i SIZfi OF LOT EXISTING BLDG I �
I certifv that m the oLrtormance of lie w)rk or ,lith his _—
permit is issued I shall not employ lni oe son nan% manner OWNER � (A LZ� 4r I� —
so as to become subject to the Rorker, Compensation Law, MAIL OCCUPANC't GROUP
I Date %pplicant ADDRESS O
NOTICL TO kPPLIC INT It .0 er-nakm_ Itis(Lrt.tiLare if IT r Q NOL OCCUPAN—LOAD
Exemption ,ou ,hould become ,uoiect o the Anrke s APOLICA—ICN e:)R EXIT HARDIVAPE
Compensation pro%isions of he Labor i.ode ,ou *rust torch
1 aith compty with suLh props ons Lr hi, ^ermat ,hall be RAILER USE El GEOLOGY NSPECTION
deemed rooked No Soec Kqoivl
LKENSLDCONTRXLTORS DECLARATIO\ OCCUPANCY INSPEC-ION3nC Panic Devices
1 hereb, affirm hat I am licensed unde provisions of Chapter SAFETY PERMIT .^.. (LIST ITEMS BELOW)
I 9 icommenLing with Section "0001 of Dnision o at the Busi- NO OF EXITS
ness and P otessions Code and ml license is in full force and
etfec PARKING
SPGCfiS REO O O PROVIDED
N
cLicense \umber L c Class LIMITED TIME USE
LL
I� Contractor Date DATE DATE
W F40M TO
ZZ I am exempt from the ltiLnsine reautrement, u 1 am i
m I ' licensed architLct or 1 maistered protevuonal envineer IME OF No of INSPECTOR s
Z acting in n, protissional araat S ion "it 1 Bits ._"..TING BLDG •-oRI SWrATURE
m )mess and P otessicns Code►
PRESENT USE OF BUILDING FINAL APPROVAL
Lac or Ree No D1,L
RE 1
HOME 01%NCR BLILDER DECLAR MON No OF EXISTING BUILDINGS �G tJtJ—tJtJ�l 6/ .fir A �1 1 +. 77
I hereby affirm that I am exempt from
LOT AND USE m the ContraLtor s 11'V I 4154 1 F� 4•�4
1 License Law for the following reason ISei tion "031 a Bust
ness and P ofessions Code) NO PARKING
I as -)weer of the propertv wall do the work and the SPACES PROVIDED
strut ure is not intended or offered for sale fSeLtion 1�
1 7044 Business and Professions Code) v
LOASTRLCTION LENDING AGF\Cl g PROPOSED USE OF BUILDING
1 hereby affirm that there is a Lonstruction Iendina a¢encv N bte�•�v
1 for the performance of the work for which this permit as
issued i SeL 3097 Civ C)
Lender s Name
PROPOSED MAX OCC
Lender s %ddre,s
I 1 certify that I have read this application and state that the PERMIT FEE 2S.00
above information is Lorect I agree to comply with all County ISSUANCE FEE
�• ordinances and State laws relating to building construLtion
and hereby authorize representatives of this County to enter TOTAL FEE 25.010
1 upon tht.abo%e mentioned property for inspection purposes
SEL REVERSE FOR EXPLANATORY LANGU 1GE
�i Uf r'til/
A f Signature of Pernrtte Date
t
1 WORKERS COMPENSATION DECLARATION 20�0003DPWi2,90 MISCELLANEOUS APPLICATION
I I hereby affuin that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
riiaBnm of a certificate of Workers Compensation Insurance,or
( 1 a eertified copy thereof(Sec.3800 Lab.Q
Pbhcy Na CompanyFOR APPLICANT TO FILL IN BUILDINGBUILDI ADDRESS ADDRESS
® Certified copy is hereby furnished X r6f IS' LOCALITY
iiSiL d copy is filed with the county budding inspection CITY ` ZIP,, 9`,� eNAARREST
depST
Date r Applicant SIZE OF NO OF BLDDGGS NOW ON LOT DISTRICT NO GRouP TYPE PROCESSED SYI CON"
0
CERTIFICATE OF EXEMPTION FROM WORKERS t
l i COMPENSATION INSURANCE TRACT BLocK LOT No MAP ice„ `
NO
(This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL I STATE MAJOR SECOND LOCAL OI
by the permit is for one hundred dollars ($100) or less) ma
USE zoNe SPECIALL CONDITIONS
t I I certify that in the performance of the work for which this r Omer
permit is issued I shall not employ any person in any manner r 3
W a
so as to become subject to the orkers Compensation Laws ADDRESS x 0�� OCCUPANCY GROUP v
( Dau Applicant CITY rYIP ?
NOTICE TO APPLICANT If after making this Certificate ' � L �!!
of Exemption you should become subject to the WorkersOCCUPANT LOAD
Compensation provisions of the Labor Code,you must forthwith APPIJCATION FOR EXIT HARDWARE
( comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl El'
revoked.LICENSED
OCCUPANCY INSPECTION I Panic Devices ❑
LICENSED CONTRACTORS DECLARATION ,
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (Liar rrams eELowi
I I 9(commencing with Section 7000)of Division 3 of the Business o its ss NO or incus
and Professions Code and my license is in full force and effect J am ^
Cl
PARKING REQ D PROVIDED
� 1 License Number Lie Class SPACES
( i Contractor Date LIMITED TIME USE
2 '
I ❑ I am exempt from the licensing requirements as I am a FROM DATE To DATE
' licensed architect or a registered professional engineer
acting III my professional capacity(Section 7051 Business SIZE OF NO or INSPECTM S
{ i and Professions Code) EXISTING BLDG STORIEg siGNw RE-
Lim or Reg No - Dat PRESENT USE OF SUSAING FINAL APPROVAL
I HOME OWNER BUILDER DECLARATION NO OF EXISTING euILDINGS
j ON LOT AND USE
I hereby affirm that I am eiaesnpt from the Contractor s License
Law for the following reason (Section 7031 S Business and
I Professions Code) NO PARKING
I F-1I as owner of the property will do the work and the SPACES PROVIDED
I structure is not intended or offered for sale(Section 7044 PROPOSED USE OF BUILDING Sea it
Business and Professions Code)
t '
I CONSTRUCTION LENDING AGENCY
1 I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
( i (Sea 3097 Civ C) PROPOSED MAX occ
1 Lander s Name APPLICANT(Ralf) TEL NO
Lender s Address ffA
( I certify that I have read this application and state that the
above information is correct. I agree to comply with all County A � 4ordinances and State laws relating to budding construction and eA `!-7County to enter uponthe above-mentioned property for inspection purposes '
I
SEE REVERSE FOR EXPLANATORY LANGUAGE
na ire of rmittee Dole