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Home My Public Portal About5622 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76nn444 I��E L LA N E®l�S APPLICATION {� LI I hereby affirm that 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,e,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN ADDRE3SNG�� Pa D.DR Certified copy is hereby furnished. BUILDING .G� �� ` L` b LOCALITY ADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST department. �fr� Gl CROSS ST. Date Applicant NEAREST / DISTRICT NO. G OUP TYPE PR ESSED BY CROSS ST. (]�� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO.OF BLDGS. (This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. a I certify that in the performance of the work for which this C:3 permit is issued,I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. tie MAIL OCCUPANCY GROUP 9= Date Applicant ADDRESS 11U / NOTICE TO APPLICANT: If, after making this Certificate of CITY 9v+ � No.rEL.(�1q� ��—t,flG� OCCUPANT LOAD D' Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: r — — a Compensation provisions of the Labor Code,you must forth- with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING REQ D SPACES PROVIDED License Number Lic. Class ( ��' LIMITED TIME USE Contractor Date DATE DATE FROM: TO! I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, BUS EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date 0" IIIDDD HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS !�� -Cole ON LOT AND USE (� �\v\ I1 --f,��l_ 'r 11Ye y I hereby affirm that I am exempt from the Contractor's va 1713 1 AN �0.2. License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE 1/126,40 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 hereb authorize representatives of this County to enter TOTAL FEE upon the ove-.entioned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signure o ermittee ate WORKERS'COMPENSATION DECLARATION CE 875(17-84) MISCELLANEOUS APPLICATION {� CE 875 IJ I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.Q. ^Y�" Policy No.� Company FOR APPLICANT TO FILL IN ADDRESS 4 /TD Certified copy is Hereby furnished. BUDRESS ILDING V f _ D� LOCALITY AD Certified copy is filed with the county building inspection LOCALITY-r� NEAREST department. CROSS ST. Date Applicant NEARESTDI IC TYPE PR E D BY CROSS ST. {�� r 1 CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ' - COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP Hlo wAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) 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 so as to become subject to the W rkers' Compensation Laws. MAIL _ OCCUPANCY GROUP Ci y� 71I c /0 -90 ADDRESS / nJ'IIJ6 lUO Date 4� Applicant / ®® �/� NOTICE TO APPLICANT: If,after making this Certificate of CITY MAA NO No� 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 INSPECTIOI Panic Devices0 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. SPACESG REQ'D D PROVIDED License Number Lic. Class EAGt,5 C 2 LIMITED TIME USE Contractor Date DATE DATE FROM: TO: F1 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 BLD 6. STORIES GNATUR iness and Professions Code). _ PRESENT USE OF BUILDING� � Nl] FINAL APPROVAL Lic.or Reg.No. Date I NADKI MI/Jil/ P �I V- ( HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS i0 I 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- -J. ness and Professions Code): NO. PARKING 01733-533 `,1q/9 .-,— ❑ SPACES PROVIDED I, as owner of the property, will do the work and the 13,38 1 Pil 1903 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. 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 2.S CCN" upo the above-mentioned property for inspection purposes. A. �M� SEE REVERSE FOR EXPLANATORY LANGUAGE /1 D.fpD%wP��1 I/Q/lQn �D l�'�� Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm at I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL BUILDING ADDRESS � • 5�,. �/ Certified copy is hereby furnished. �/I � DILDING DRESS L Z- /V RI LOCALITY 1 i D Certified copy is filed with t11e county building inspection I NEAREST CALITY T I department. 1 ` �• � CROSS ST. Date Applicant ARES, ( DISTRICT N G UP TYPE PROr;h SED BY ROSS ST. T[ I .S ..t�J`,, `JFF,�(J7 CO_NST.:/ (�I CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v/ (/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SE ND LOCAL No. (CIRCLE) NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF a I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. o permit is issued,I shall not employ any person in any manner OWNER ' L L IFQ y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP r r2 0 Date Applicant ADDRESS ,fro , W NOTICE TO APPLICANT: If, after making this Certificate of CITY �S —LC$ NOL Z/ yS / OCCUPANT LOAD y 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 USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING REO'D I I PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a PROM? TOC licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S NATURE iness and Professions Code). FINAL APPROVAL RESENT USE OF BUILDING Lic.or Reg.No. Date 1F_,;V1 A ti' C' ►[ HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS AA�7�/�] n ON LOT AND USE C / / (.O A I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- # o o o o 8 8 ness and Professions Code): NO. PARKING SPACES PROVIDED 0 0 0 0 0 0 0 I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section a27-r-87 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY ROPO SED USE OF BUILDING 1 I hereby affirm that there is a construction lending agency �j ,surd L �/ " for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). _ Wpm �� 1.1� Lender's Name 1 PROPOSED MAX. OCC. O� Lender's Address I certify that I have read this application and state that the PERMIT FEE S'Q� above information is correct.1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upoa above-mentioned property for inspection purposes. • S)rE REVERSE FOR EXPLANATORY LANGUAGE / ��- nature of Permittee D to ✓ ..Vf(ORICER3',C9MPE1AiSATION DECLARATIONSa MISCELLANEOUS,CE B7 APPLICATION • CE 875(11-84) I Hereby'affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure., or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.C.). I Policy No. Company FOR APPLICANT TO FILL IN HUILDING � ADDRESS Certified copy is hereby furnished. BUILDING ,��a f Rim LOCALITY ADDRESS ❑ Certified copy is filed with the county building inspection LOCALITY �• NEAREST department. /�S%yJP ��/ CROSS ST. Date Applicant NEAREST A C I' �} DISTRICT NO. GROUP ITYPET., PROCESSED BY CROSS ST. A J TVA.144 S � D i/ CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAF NIG Mw AY STATE MAJOR SECOND LOCAL NOS NO. OF BLDGS. (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 /J SIZE OF LOT EXISTING BLDG. G 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 /¢ /AAC. I � 5.' so as to become subject to the Workers' Compensation Laws. � yy/,�� I!��:;��, //�� y•}�� 1 OCCUPANCY GROUP W ADDRESS MAI /000 HeJAMAJ yl�Al YAP. O Date Applicant ,` LI1 NOTICE TO APPLICANT: If, after making.this Certificate of CITY-rAAJ /YJ/►�KIAIO NOL' �Y .6 r pO OCCUPANT LOAD Exemption, you should become subject to the Workers' -- Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: 1 ❑With comply with such provisions OI this permit Shall be TRAILER USE � GEOLOGY INSPECTION El No Spec. Knowl. deemed revoked. Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION El I hereby affirm that I ani licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. of EXITS ness and Professions Code,and my license is in full force and , effect. PARKING REQ'D D PROVIDED SPACES License Number Lic. Class 00/TV 0 C/45s,677 GOpvi.+J�i, 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 S NATURE iness and Professions Code). FINAL APPROVAL _ PRESENT USE OF BUILDING Lic.or Reg.No. Date uD HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS n D /l .ON LOT AND USE (/ /�///. 1-4,11iJ""i..1`y 'v!• I Hereby affirm that I am exempt from the Contractor's WWW ('' License Law for the following reason (Section 7031.5, Busi �� 36r-511i; Pill 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). X CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency /Ip/5Wy "1210 )9 for the performance•of the work for which this permit fs -issued(Sec.3097,Civ.C.). �L 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 author' representatives of this County to enter TOTAL FEE ��• a�0 upon the ove-,12ti ned propertif for inspection purposes. 6?A) SEE REVERSE FOR EXPLANATORY LANGUAGE ; Signatuie of Permittee(/ Date tr WORKERS'COMPENSATION DECLARATION E 87 5(11-84) Ca MISCELLANEOUS APPLICATION {� •a ,,, CE 87IJ I 4ieri6y 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.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. `BAon ss S�2 Z K o3ewn ea Q Vd•i LOCALITY Certified copy is filed with the county building inspectio VOC•ALITY NEAREST department. L «1i [ Lt"r cnos.s ST. y� Date Applicant NEAREST DISTRICT NO. GROUP CONST.i// P ESSED BY CROSS ST. ITYPE CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP IIIGRw AV STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO.OR 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. p I certify that in the performance of the work for which this J permit is issued;•1 shall not employ any person in any manne}M sNER Of building O: m as to become subject to the Workers' Compensation Lads...-=- MAIL OCCUPANCY GROUP ADDRESS V Date Applicant 41 NOTICE TO APPLICANT: If,after making this Certificate of CITY No� OCCUPANT LOAD vi 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. i deemed revoked. OCCUPANCY INSPECTION� Panic Devices LICENSED CONTRAcrORS DECLARATION I hereby affirm that I ant licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code,and my license is in full force an -'NS`Ne 'f business =' a• (�AC4peM PARKING r effect. REQ,D PROVIDED -- �; SPACES L_ License Number _ Lic. Class LIMITED TIME USE Contractor Date DATE _ DATE FROM: TO: � IITa FEE Ell am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF IN SPE GTOR`S gi p tlgl SIGNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES ; -,"Q ,_• iness and Professions Code). FINAL APPROVAL PRESENT USE OR BUILDING Lic.or Reg.No. Date HOME OWNER-BDECLARATION NO. OF EXISTING BUILDINGS U L� ON LOT AND U86 � J� 1 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 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). CONSTRUCI'ION 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 __ 25.00 I certify that 1 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, :land hereby authorize representatives of this County to enter I TOTAL FEE 25-00 3 own the above-mentio ed property forsin�rlpection purposes. I ��;:;r X •Iv SEE REVERSE FOR EXPLANATORY LANGUAGE „IUltlil.Rh' U.%1NL\Jr111U,NULlLr11ir111U\ ,DM4414 MISCELLANEOUS APPLICATION CE 875{11.84) hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Isu,e, or a certificate of Workers'Compensation Insurance,or certified copy thereof(Sec.3800.Lab.Q. - olicy No. Company FOR APPLICANT TO FILL IN BUILDING V62Z Fog (� pp /� ADDRESS Certified copy is hereby furnished. pD DR E55 �6� �ZOsQ ti+IC A 61d LOCALITY ] Certified copy is filed with the county building inspection LOCALITY NEAREST department. K CROSS ST. L_e, �41,a )ate Applicant NEAREST DISTRI NO 7UP ITYPE 1-7- CROSS BY CROSS ST. LQ UN 6 U(X/ CONST l CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NMADP HIGHWAY LEI 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 -y the permit is for one hundred dollars (5100) or less.) USE of SIZE OF LOTEXISTING BLDG• certify that in the performance of the work for which this -- errnit is issued, 1 shall not employ any person in any manner OWNER as to become subject to the Workers' Compensation Laws. CO' OCCUPANCY GROUP I /f7L�Ji MAILI� ADDRESS loon A.1 I) y- )ate Applicant x = r TEL' - 40TICE TO APPLICANT: If,after making this Certificate of CITY p y gad(;o. No. �(-Loy- 0 OCCUPANT LOAD xemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE. — ompensation provisions of the Labor Code,you must forth- ith comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ ❑ ❑ No Spec. Knowl. .eemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ® Panic Devices hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITBELOW) (commencing with Section 7000) of Division 3 of the Busi- E NO. of EXITS Tess and Professions Code•and my license is in full force and ffect. PARKING SPA IN REq•D PROVIDED .icense Number Lic. Class LIMITED TIME USE ontractor Dale DATE DATE I-ROM: TO: 1 am exempt from the licensing requirements :Is I am a licensed architect or a registered professional envineer slzE of NO. OF INSPECTOR s acting in my professional capacity (Section ;051, Bus- EXISTING BLDG. STORIES SI TUR iness and Professions Code). �^ � PRESET USE OF BUILDING FINAL APPROVAL .ic.or Reg.No. --- Date--- __---- Alr- HOME OWNER-BUILDER DLCL•1RATION ONO. OF N LOT XI use BUILDINGS hereby affirm that I am exempt front the COI1MICIOr'S �00 �a .icense La«• for the followin,' reason (Section 7031.5. Busi- Ip^ less and Professions Code): No. PARKING ��p ] I, as owner of the property. will l do the tl orl. :n1d the SPACES PROVIDED structure is not intended or offered for mle (Sectio(( 7044,13usiness and Professions Code). — - - ------ --- — CONSTRUCTION LLNDING1 \GL\Cl PROPOSED USE OP BUILDING hereby affirm that there is a construction lending agenci m�,{klI — 1/ �� r >M 4111` or the performance of the work for which this permit 1s ;sued(Sec. 3097.Civ.C.). Y0�(i de{, .ender's Name PROPOSED MAX. OCC. .ender's Address certify that I have read this application and state that the PERMIT FEE dU Ibove information is correct.I agree to comply with all County f ISSUANCE FEE )rdinances and State laws relating to building construction, Iiia 'hereby authorize re resentatives of this County to enter TOTAL FEE , CC (p,:n the abo a ention properf lspection purposes. 51:I RI'\'1•]ZSI' 1.OIZ I'\I'l.:\N:ITORY LANGUAGE VF Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76%1"74 MISCELLANEOUS APPLICATION ' I p 70-0063DPW12/90 I + I Ihereby atWorkers'affirm thlof have cerCficate f ci sent to or self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION re I a certified copy thereof(Sec.3800• Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING /a �l i BUILDING ADDRESS 4DDRE IS fo d� —1Certified copy is hereby furnished. rcj�jZ Z uk LOCALITY I ❑ Certified copy is filed with the county building inspection CITY zipQ 4' department. Teti>n -1 f NEAREST CROSS ST. toe I Date Applicant SIZE OF LOT ,� _ �7 NO. BLDGS.NOW ON LOT DIS T Nf� GRO TYPE ESSED BY i ��U /1 i" CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO. AP !/!! NN" COMPENSATION INSURANCE MAP HIGHWAY STATE MAJOR SECOND LOCAL No. (CIRCLE) (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (S 100) or less.) ➢ I certify that in the performance of the work for which thisOWNER . `/ TEL NO.p permit is issued.I shall not employ any person in any manner Property -h---SOL so as to become subject to the Workers' Compensation Laws. ADDRESS nOCCUPANCY GROUP 1 Date Applicant CITY - q�t� i OMS' ZIP NOTICE TO APPLICANT: If. after making this Certificate• � � OCCUPANT LOAD of Exemption. you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code.you must forthwith 1 comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ revoked. OCCUPANCY INSPECTION❑ Panic Devices ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter S FETY PERMIT❑ (LIST ITEMS BELOW I 9(commencing with Section 7000)of Division 3 of the Business NO.OF EXITS El and Professions Code.and my license is in full force and effect. r� e PARKING• REO'D I I PROVIDED i License Number Lic.Class SPACES LL__JJ J ► Contractor Date LIMITED TIME USE DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer - INSPECTOR'S acting in my professional capacity(Section 7051.Business EXISTING BLDG. STORIES sl TORE and Professions Code). Lie.or Reg. No. Date PRESENT USE OF BUILDING �� FINAL APPROVAL I HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS JJ1y /��/ I I hereby affirm that I am exempt from the Contractor's License ON LOT AND USE Law for the following reason (Section 7031.5. Business and 1 J Frofessions Code): NO.PARKING /!!� SPACES PROVIDED ❑ 1, as owner of the property will do the work and the ` structure is not intended or offered for sale(Section 7044X PROPOSED USE OF BU ILDINGts ' CcOe�d�� Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec.3097,Civ.C.). PROPOSED MAX.OCG Lender's Name APPLICANT(PRINT) TEL NO. Lender's Address 4DDRESS I certify that I have read this application and state that the above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction•and hereby authorize representatives of this County to enter upon ISSUANCE FEE the a - tioned property for inspection purposes. TOTAL FEE � I 7 SEE RE\'FRSE FOR EXPLANATORY LANGUAGE W ) Signature of Permittee Date