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HomeMy Public PortalAbout5417-5429 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 W I S C E L LA N E O U S APPLICATION CE 875 (2-80) I hereby affirm that I have certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' rs'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No.-. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS .LJ �• ❑ Certified copy is hereby furnished. BUILDING O /� LOCALITY t ADDRESS �1/I Certified copy is filed with the county building inspection ��1vf;f3p� rj NEAREST department. LOCALITY ceoss ST. ' Date Applicant AEAREST DISTRICT NOGROUP TYPE P CESSED BY CROSS ST. O r ` ij CONST. ' CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL CL} NO. OF BLDGS. NO. (CIRCLE) 0 O (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.) USE OF /J 2 cc SIZE OF LOT EXISTING BLDG. 1 certify that in the performance of the work for which this 11 O permit is issued, I shall not.employ any person in any manner OWNER 11- so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP 2 0 MAIL W ADDRESS CL Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of CITY NOL .� d OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you,must forth- • APPLICATION FOA 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 ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS , 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and 0z o effect. / PARKING• RED.'D D PROVIDED D SPACES License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: DI am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG.' ///` {{{ STORIES SIGNATURE mess and Professions Code). PRESENT USE OF BUILDING TJ_/(y - FINAL APPROVAL Lic.or Reg.No: Date t v l(r HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �-- ON LOT AND USE - � '� EE 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 ❑ 1, as owner of the property, will do the work and the 1 'ni structure is not intended or offered for saleSection f 7044, Business and Professions Code). ( I PROPOSED USE OF BUILDING l`-f CONSTRUCTION LENDING AGENCY I hereby' affirm that there is a construction lending agency for the performance of the work for which this permit is UD issued (Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE a15, I certify that I have read this application and state that the above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE n� andereby thorize represent tives of this County to e, on t bove-me tioned pr perty for inspection purpostYS. SEE REVERSE FOR EXPLANATORY LANGUAGE I cure IJAPermittee Date - . WORKERS'COMPENSATIONDECLARATION 76M444 MISCELLANEOUS APPLICATION i• CE 875 (11-84) I hereby af� m that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insu ,,•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. BUILDINGs(�S 2—TY PX�SV XAD BLV LOCALITY Tr , DDRESS (.� 0 Certified copy is fild:with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEARESTy����//�� DISTRICT " GXU T PE / PROS€ SED BY CROSS ST.�I`Of��Wr"► /./ 1/' CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SEC&4D LOCAL _ NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this I o permit is issued, I shall not employ any person in any manner OWNER G A y so as to become subject to the Workers' Compensation Laws. MAIL y+ r `J OCCUPANCY GROUP. o ADDRESS ,L NT Q.v� C_5Date Applicant w g SIL AM 41�8�3NEL ^1 i3 26S A) OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY o. LI 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. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING REQ'D O PROVIDED D . SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE iness and Professions Code). �-1�J �l �J PRESENT USE OF BUILDING y,/N� FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 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). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING �'�LLl1f�T ,0 2 5 8 I hereby affirm that there is a construction lending agency # � � � ® 8 for the performance of the work for which this permit is In issued(Sec. 3097,Civ.C.). / �' -A?-� IPNL-L SU' L(Es p �' Lender's Name PROPOSED MAX. OCC. Lender's Address , a I certifyPERMIT FEE that I have read this application and state that the ° 1 y above information is correct.I agree to comply with all County ISSUANCE FEE I �1 ordinances and State laws relating to building construction, Q and'hereby,au Ives of this County to enter TOTAL FEE t U70 d propert forinspection rposes. /ng SEE REVERSE FOR EXPLANATORY LANGUAGE r 7' i of itte Date I VORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C A T I O N in hereby affirm that I have a certificate of consent to self 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.Q. 40 4 Policy No. Company FOR APPLICANT TO FI LL IN BUILRDESSING L '1 p� ADD Certified copy is hereby furnished. BUILDING 5—,1ZQ $e / alb /� ADDRESS .tt,7/ LOCALITY l..- 0 Certified copy is filed with the county building inspection LOCALITYo NEAREST department. an Q�oY�Q� �� cR0.. ST. Date ApplicantNEAREST DISTRICT NQ/ G OUP TYPE PRO/ SS BY CROSS ST. CONST. IV/ - CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL JVI COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SE ND LOCAL NOOF BLOGS. (This section need not be completed if the work involved TRACT NO.W ON LOT USE ZONE SPECIAL CONDITIONS by the permit is.for one hundred dollars ($100) or less.) SIZE OF LOT / USE OF ( ��j a S/= EXISTING BLDG. I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manner OWNER ARNZI /l7 r i' s') so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS Z F C!) eo _TV t•— Date Applicant n TEL' NOTICE TO APPLICANT: If, after making this Certificate of CITY 56ill I LQ No. OCCUPANT LOAD v� Exemption, you should become subject to the Workers' Vz Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. El deemed revoked. OCCUPANCY INSPECTIO Panic Devices El LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- . NO. OF EXITS ness and Professions Code, and my license is in full force and effect. PARKING SPACES REQ'D PROVIDED License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: D I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSP CTOR S acting m my professional capacity (Section 7051, Bus- XISTING BLDG. STORIES S NATURE iness and Professions Code). FINAL APPROVAL �I // PRESENT USE OF BUILDING ""7 S7 [ /1� J // Lie.or Reg.No. Date !! / A e/l C/� N2 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's 8 5 2 4 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING #,oro o o 88 SPACES PROVIDED I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044,Business and Professions Code). 1 '2 0 6 8 7 CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE ' I certify that I have read this application and state that the above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE u the aboveed property for inspection purposes. G SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date .,WORKERS'COMPENSATION DECLARATION 76M444 CE 875 (11-84) MISCELLANEOUS APPLICATION {� I hereby affirm that I have a certificate of consent to self COUNTY OF LOS'ANGELES BUILDING AND SAFETY DIVISION LI ms}tre, 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 ! Al— Certified ADDRESS . / Certified copy is hereby furnished. ASUILDING L4 �, A LOCALITY ADDRESS LJ 0 Certified copy is filed with the county building inspection LOCALITY , NEAREST department. ORoss ST. Date Applicant AREST / DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. Vy�' CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �"O 6; COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP `` LL—"IGHWAY (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) _ USE OF I certify that in the performance of the work for which this slzE of LOT EXISTING BLDG. o permit is issued, I shall not employ any person in any manner OWNER `A .©CA41zcj so as to become subject to the Workers' Compensation Laws. ) ) OCCUPANCY GROUP, tAMIL DRESS Date Applicant I LLu NOTICE TO APPLICANT: If, after making this Certificate ofv 1M� TNo� Gam' OCCUPANT LOAD Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. El deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI ❑ (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. PARKINGSPACES REQ'D D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: D I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF I SIP NATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). ��y/ PRESENT USE OF BUILDING CAVjl J �+ �p �q FILIAL APPROVAL Lic.or Reg.No. Date ll {W� vvvv���,���` i L-V1 c/ HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING ElI, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). 22 8 6 6.4 A CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING PS # 0 0 0.0 3 0 I hereby affirm that there is a construction lending agency 0 0 0 D o.0 0 for the performance of the work for which this permit is' issued(Sec. 3097,civ.C.). 1 227-87 Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the ((P,�-E., • above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State lap =1s relating to building construction, and hereby authorize representatives of this County to enter TOTAL. FEE ` 6 n the biove7jDentioned prope ty ' spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE u Si ure of Permitt e Date t WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION 'fl I hereby affirm that I Have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,4r 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 ❑ CeItified copy is hereby furnished. BUILDING LOCALITY ADDRESS ^ / �cC . 0 Certified copy is filed with the county building inspectionia I��(/, NEAREST department. L�( CROSS ST. Date Applicant DIS IC'Lf L( _G R - TYPE PROCESSED BY SU7V/, 1.59�NS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK HWAY NO. (CIRCLE) STATE MAJOR ECO ND OCAL 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 SIZE OF LOT EXISTING BLDG. >0-- permit " I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL ; O OCCUPANCY,GROUP o ADDRES � f4?�2 ~ Date Applicant Lail NOTICE TO APPLICANT: If, after making this Certificate of C-26? T. 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. EJ deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- No. of EXITS ness and Professions Code, and my license is in full force and effect. PARKING SPACES REQ'D E� PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE iness and Professions Code). ' FINAL APPROVAL PRESENT USE OF BUILDING / Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS 0 0 0 0 0 0 • z ON LOT AND USE I hereby affirm that I am exempt from the Contractor's t 12 06-87 License Law for the following reason (Section 7031.5, Busi \ ness and Professions Code): NO. PARKING ElI, as owner of the property, will do the work and the SPACES PROVIDED \^np 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 agency0_1 It 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 00 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 here authorize re sent at Ives of this County to enter TOTAL FEE ' 15 up t bove ent' n d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signat of Pe mittee Date WORKERS'CGMPENSATION DECLARATION 76M444 CE 875 (11-84) M I SC E L LA N EO U S APPLICATION r I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDIING ADDRESS Certified copy is hereby furnished. IUILDING CJL4'�ri aSGyrveo e(. 1�L ADDRESS LOCALITY I 6,41 DCertified copy is filed with the county building inspection OCOCALITY (r NEAREST department. N, �e �N'"^�" CROSS ST. Date Applicant NEAREST �p�-d DISTRICT NO. GRV. TYPE PROC SS BY CROSS ST. h L7 YV y �%- {�\� / CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J U iyl U COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCI-E) STATE MAJOR SEC D 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 SIZE OF LOT EXISTING BLDG. d I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manner OWNER A TU—IT 1>R,I C_> so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUPFT Iz AIL O ADDRESS YVDL_E So � �VAo- - {Tve Date Applicant L. L�IJ NOTICE TO APPLICANT: If, after making this Certificate of CITY I I1�S�A t�Y NO. OCCUPANT LOAD Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: _ with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑% (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 I� effect. PARKING SPACES REQ'D D PROVIDED L�-J 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 SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE iness and Professions Code). Lie.or Reg.No. Date 4 PRESENT USE OF BUILDING FINAL APPROVAL Ot�(>r H OCAr PH 0-TO . HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 35,5A ON LOT AND USE # 0 0 o.0 8 8 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- o D D o a o o z ness and Professions Code): NO. PARKING 0 I, as owner of the property, will do the work and the SPACES PROVIDED 1 1, 1 3 8 7 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 (y c� (\( � �( o cAr p{t a'rb OA- for the performance of the work for which this permit is 1l 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 ,00 above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby autho ' e representatives of this County to enter TOTAL FEE (}� on the above- ntione perty for inspection purposes. i SEE REVERSE FOR EXPLANATORY LANGUAGE e Signature of Permitte Date ,NORKEItS'COMPENSATION DECLARATION CE 875 (t 1-84) MISCELLANEOUS APPLICATION {� CE 875 LI 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 L'I C71� FOR APPLICANT TO FILL IN BUILDING C3 +,3.I ADDRESS 7 ® Certified copy is hereby furnished. BUILDING 5q ADDRESS osEµ LOCALITY ��� �`�I/ 0 Certified copy is filed with t county b 'ding inspection. LOCALITY '5 � ( •J� NEAREST dep rt t. I+ K`7 �Y► CROSS ST. Date 3 19 4�` Applicant NEAREST DItZONEISPECIAL NO. G OUP TYPE PROCESSED BY CROSS ST. � CONST.CERTIFICATE OF EXEMPTION F OM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAHIGHWAYNO (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work Involved TRACT NOW ON LOT USCONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. r I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manner OWNER 64 $ so as to become subject to the Workers' Compensation Laws. MAIL I OCCUPANCY GROUP o ADDRESS Date Applicant l M LO NOTICE TO APPLICANT: If, after making this Certificate of CITYNL_VVA,--g�. No. (Z13 �2$3—`J l oI 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. El 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. �( i!•••W I1u�" PARKING REQ D PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: 1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS SIGNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). I I _ i2S `I FINAL APPROVAL luql­�L PRESENT USE OF BUILDING ti'1°► Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE � d' I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi f r ";``_''i•'. ness and Professions Code): NO. PARKING _ SPACES PROVIDED I, as owner of the property, will do the work and the I structure is not intended or offered for sale (Section 7044,Business and Professions Code). V CONSTRUCTION LENDING AGENCY /` PROPOSED USE of BUILDING ui.1GSM.�r I 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.). ( Gb A--! G-/Sri Lender's Name PROPOSED MAX. OCC. Lender's Address 44!! 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, II and hereby authorize representatives of this County to enter TOTAL FEE upon the ab ve-mention property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I G� I pl L- Signatur of Permittee Date I WORKERS' co'vlPLvs.-vTION DLCL_vR.arloN 76vt444 MISCELLANEOUS A P P L I C A T I 0 N - CE 875 ill-841 I herebv affirm that L have a certificate of consent to self t insure. or a certificate of workers Compensation Insurance.or COUNTY OF LOS .ANGELES BUILDING .AND SAFETY DIVISION �f a r7rtified copy thereof(Sec. 3800.Lab.C.I. ,�► Policy No. _Cont an} BUILDING p" FOR APPLICANT TO FILL IN ADDRE 5 I/ Certified copy is hereby furnished. BUILDING' �� yl/i1 el TY ADDRESS ���/ �✓77J I 0 Certified copy is filed with the counts building_ inspection LOCALITYNEAREST department. Temple City CROSS ST. Date Applicant NEAR EST DISTRI T N P TYPE .P ,OCESSED BY ' CROSS ST. CONST ► CERTIEIC.aTE OF EXEMPTION FRO�('\'ORI:ERS LEGAL GR�u � COMPENSATION INSURANCE ! OESCRIPT!ON LOT NO. BLCCK !r+wv IG Hw Av I ^�o (CIRCL_I STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved 1711AC: NON ON LOT USE ?ONE SPECIAL CONDITIONS by the permit is for one hundred dollars (51110) or less.) USE OF 1 SIZE OF LOT EXISTING BLDG. I certify that in the nedonnance of --lie '.cotl: or .chick -his permit is issued. I sltall not empiov am ne:son '.n an, manner OWNER +_ so as to become suttject :o the ',vorkers' C.tm ensatian Eaws. TL �lSE MAIL r- OCCJPANC1:' .;ROUP — ADOR ESS 5 � ��'/J 1 Date _ Applicant NOTICE TO APPLICANT: If, at,er rnakin; '.his C:crtiiiCuc '.0 %1 CIT•( Ma, uo1 CCCUP4N7 LOAC Exemption. VOLT should become subiect :o !It, W—kers Compen&-inon provisions of the Labor -__ode. you must for'h- I APDL!CATiCn! =OF. - i with compi%- with such provisions or :itis 7ermit shall he I , _ — TRAIL=R ;JSE GEO LJ GY ;N cP E',..� Y :ONo Spec. K��O!•tl I l: deemed;eoza. — L. n OCCUPANCY INSPECTION$$ Panic Devlres LICENSED CONI RAC.TORS DECLARATION I hereby :ul1Im .hat I am licensed Under pro%'isionso Citaptl'r SAFETY PERMIT ';V LIST ITEIAS BELL N) rn I 9 (comencing with Section '0001 of Division 3 of rhe Busl- NO. OF EXITSEl ness and P-ofessionc Code, and my license is inAil] force and / effect, PARKING REO'D PR C`J ID ED ,L License Number Lic. Class LIMITED TIME USE N Contractor Date _ -1E .ATE w ? ❑ T. am exempt from the ticensine reauum eents as l am .t 9 i licensed architect or a IeListered ornfessional engineer ;IZE of NO. OF NSPECTO s Z :lltm� in .n\' professional ..1Ca::li'' -5«i10:1 (�4! I31IF EXISTING BLDG. STORI-S SIGNATU E inessandProfessicnsCode). FINAL APPROVAL C J/\► U PRESENT USE OF BUILDING a•r/J Lic.or Rei. No._____ Da-,.c I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE O � s• ••: ?�'-'�:I_.a ,I,i I herebv affirm that 1 am exempt from the Contractor's I License-Law for the following reason (Section 7031.5. Busi- ness and Professions Code): NO. PARKING (/v/ 1, as ,owner of the proper[}'. will do tile SPACES PROVIDED e Ivork and the 1111 strucatre is not intended or offered for sale (Section I 704.3. Business and Professions Code). CONSTRUCTION LENDING AGENCI X PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agencv Q i/C use for the performance of the �%ork for Miicli this permit is issued (Sec. 3097•Civ.C.). m//--wc q— 5? E S Lender's Name PROPOSED MAX. OCC. Lender's.address _ ( I certify that l have read this application and state that the PERMIT FEE 25.00 above information is correct. I aeree 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 1 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I � — i Sienature of Permittee Date