HomeMy Public PortalAbout6264-6276 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION a
CE 875(11-84) MISCELLANEOUS APPLICATION
CE 87
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 BUILDING /
ADDRESS l/i/�
Certified copy is hereby furnishedBUILDING LOCALITY
ADDRESS 6272- Rosmecri Blvd.
DCertified copy is filed with the county building inspection OCALITY NEAREST
department. T le Ci CP CROSS ST
Date Applicant NEAREST i DISTRICT NOGR U TYPE /f P OC SED BY
CROSS ST O CONST.
/ {/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCKMAP G` HIG Hw Av
NO. OF BLDGS. NO/�3• (CIRCLE) STATE MAJOR SECOND LOCAL
�vv
(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, �v
I certify that id the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER = r -'
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY�GROUP s � �/ a
10/ ADDRESS 13583 '•� - -
Date Applicant
NOTICE TO APPLICANT If, after making this Certificate of CITY (' rTao _ 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 oI this permit shall be TRAILER USE GEOLOGY INSPECTION
deemed revoked. 1 ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION`4 Panic Devices El
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 REpID PROVIDED
SPACES
License Number Llc. 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 INSPECTORS
acting in my professional capacity (Section 7051, Bus- E (STING BLDG. STORIES S GNATURE
iness and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL
Lic or Reg No. Date S
HOME OWNER-BUILDER DECLARATION NO. OP 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
I, as owner of the property, will do the work and the SPACES PROVIDED ;2536, 1 A
structure is not intended or offered for sale (Section
'7044,Business and Professions Code). # 0,0 0 0 88
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING Business es �' (�`� 0 0 0 **a 0 o z
I hereby affirm that there is a construction lending agency h \/ 4 O Q 4 i 8 6
for the performance of the work for which this permit is v
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, JVV
and hereby authorize representatives of this County to enter TOTAL FEE
upn the above-mentioned property for ins ctlon purposes.
SEE REVERSE FORE LANATORY LANGUAGE
Signature of Permittee Date
1'
WORKERS'COMPENSATION DECLARATION I CE 875(11-84) M ISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self - ,.�'
insure; or a certificate of Workers'Compensation Insurance,or OUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �f
a certified copy thereof(Sec. 3800,Lab C)
Policy No. CompanyFOR APPL CANT O FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. } BUILDING (LL
ADDRESS (}SL" LOCALITY
Certilied copy is filed with the county building inspection LOCALITY NEAREST VVV
department. CROSS sT
Date Applicant NEAREST DISTRICT G O YPE PRO� ED BY
CROSS ST /rte �l ONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 5vLz
COMPENSATION INSURANCE DESCRIPTION Lor No YX BLOCK MAP HIGHWAY
` No IS'�j2�j I iRCLE) 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'
I certify that in the performance of the work for which this SIZE of Lor EXISTING BLDG. �' o
permit is issued, I shall not employ any person in any manneTv OWNER �17 �P�� ='
so as to become subject to the Workers' Compensation Lawsv OCCUPANCY GROUP - ' ' 7 —
Date
O
ADDRESS ��� . ..{- Li/I�.' - .�
Date Applicant -
NOTICE TO APPLICANT- If, after making this Certificate Of CITY 5 ( Q rlo. - ?q 1 OCCUPANT LOAD
Exemption, you' should become subject to the Workers' APPLICATION FOR EXIT HARDWARE
Compensation provisions,of the Labor Code,you must forth El-comply. with such provisions Or this permit shall be TRAILER USE GEOLOGY INSPECTION
deemed revoked. EJ Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
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 D PROVIDED D
License Number Lie. Class LIMITED TIME USE
Contractor Date DATE DATE
F] I am exempt from the licensing requirements as I am a
ROM. TO
licensed-architect or a registered professional engineer SIZE OF NO OF FINS PE TOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIG ATURE
mess and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING Gc/
Lie.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
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). ;9 6 7,11'.6 A
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY - , # o e o 0 8 8
I hereby affirm that there is'a construction lending agency ' - e^e o 0"a;o o
for the performance of the work for which this permit is •'
issued(Sec. 3097,civ.Q. 0 '7.2-3 . 8 7
Lender's Name
Lender's Address
PROPOSED MAX. OCC.
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 l`
upon the above-mentioned property for inspection purposes. �•
' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
-WOR S'COMPENSATION DECLARATION CE 875(2,-80)
•'amu I SC_ E L ISA 1 tl E O U A P P IL 0 C A 1 I®1�7
I hereby affirm tliat I 'have a' certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �•,
insure, or a certificate of Worker`s'Compensation Insurance,or {
A certified-copy thereof,(Sec 3800,LabC y
Policy No Company FOR APPLICANT TO FILL IN' BUILDING ,
r v - ADDRESS 6 IV
D Certified'copy is hereby furmsfied' i i • BILDING /!_ �t G ,A 1�
LOCALITY
U
❑ v ADDRESS• Y3 PLOT-f.��T .1�^' 1�_ •.
Certified copy is,filed`with•the-county i
building nspection' NEAREST
department` LOCALIT,Y_'� ^ i✓ t (� CROSS ST
d rl
Date Applicant NEAREST _ DISTRICT NO. ROUP TYPE / PRO E ED BY
CROSS ST 5 CONSTV//'
_CERTIFICATE OF EXEMPTION FROM,WORKERS:' LEGAL "T ` ���///
COMPENSATION INSURANCE "" , DESCRIPTION LOT NO BLOCK MAP HIGHWAY } .
' NO (CIRCLE) STATE MAJOR SEC D LOCAL' Q.
NO OF'BLD6S
(This section need'-not`be completed if the work`itivolved TRACT NOW ON LOT USE ZONE SP ECI AL-CONDITIONS O
by' the permit, is for-one hundred• dollars\"($100) or less.). t
USE-OF
SIZE OF LOT EXISTING BLDG G'�(/ } Cr_
certify that in the performance of the`Owork'for.'whlch this, Q
permit is Issued,•I shall not employ any.persoti in-any manner-` OWNERSL ti U
so as to become subject to the Workers' Compensation Laws MAIL a^, ,- AA_( �` OCCUPANCY GROUP F 9
W
ADDRESS (o 21 2_ 'N• M1�'�G t-AS � d
Date Applicant -. s. Z,
TE
NOTICE TO APPLICANT If, after,making this Certificate Of,'t,'CITY rE(✓L L� L'( C Noi 2 6 t9 , SU OCCUPANT LOAD ,
Exemption, 'you should, become subjects to tfie'Workers' APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth- "
with comply with such provisions-or"'ibis permit shall be
deemed revoked TRAILER`USE - GEOLOGY INSPECTION E3 NO Spec. Knowl
-
.,
" ', "`- ' �
LICENSED CONTRACTORS DECLARATION_ OCCUPANCY'INSPECT•IOn Panic Devices
�I.hereby affirm that I am licensed under provision"s,of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO OF EXITS
9 (commencmg with Section 7000) of Division 3 of She Busi-
ness and.,Professions Code;''and riiy license is in,full,force and,'
PARKING. '
effect REQ'D �' PROVIDED L�
• •€, - \ SPACES '
,License Number - LIc Class
LIMITED TIME USE ,
ontractor ' ;Date
CDATE' DATE
❑ c r � .. >'. .-. � ` V - FROM TO
I am' exempt from the licensing requirements as I am a s
C INS ECT-R'S
licensed architect or a registered Iprbfessional engineer, .SIZE OF rvo OF;-
-acting in my professional capacity (Section 7051, BUs- EXISTING BLDG. STORIES S GNATURE
iness,and Professions Code). FINAL APPROVAL
ESENT USE OF'SUILDING �C�h;�A \L' C t,t� _•
Lic,or Reg.No i :Date `-
HOME OWNER-BUILDER DECLARATION No. of EXISTING BUILDINGS, ;2259,6A
ON LOT AND,USE -
I hereby affdm that I am';exempt' from the`Contractor's
License Law for the following reason'(Section 7031 5, Buss-
ness and Professions Code)- NO. PARKING 0 0 0-0 a
SPACES PROVIDED _
k�
I, as owner of the property, will do the work'and the _ _ - • - ."_ _- a,06-8 5 •
structure is' not intended or,offered for sale (Section
7044, Business and Professions Code').. y
I -POSED USE OFBUILDING
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'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 hagree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, }, Y
and hereby authonz representatives-of this County to enter TOTAL•FEE,\
upon th above-me i ned property for mspectl n urp ses SEE REVERSE-FOR EXPLANATORY LANGUAGE
Signature of Pe mittee D e
WORKERS'COMPENSATION DECLARATION
CE 875 (11-841 MISCELLANEOUS APPLICATION
' CE 875 _
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 cef(ified copy thereof(Sec 3800,Lab C). 'fl
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING
ADDRESS 2 `f'✓!„��
Certified copy is hereby furnishedBUILDING LOCALITY
ADDRESS •�--
0 Certified copy is filed with the county building inspection LOCALITY , NEAREST
department. ! CROSS ST.
Date Applicant NEAREST DISTRICT ��I'''jjj0/ GI UP TYPE / PROCE 5ED BY
CROSS ST /i CONST. r'/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L/1 L UUA IIIJJJ YYY
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR EC D LOCAL
NO. OF BLDGS.
(This'sectionneed not be completed if the work involved TRACT NOW ON LOT USE ZONE IAL CONDITIONS
by the permiSPEC
t is for one hundred dollars ($100) or less.) Us OF of
I certify that in the performance of the work for which this IZE of Lor EXISTING BLDG d
permit is issued, I shall not employ any person in any manner OWNER A i Sivt �" - i y
so as to become subject to the Workers' Compensation Laws MAIL .,000UP,ANCY�GROU P ti
Date Applicant I/IZADDRESS g - ., �. I—
UNOTICE TO APPLICANT If, after making this Certificate of' v�Q,iyl noL�5— ( � � OCCUPANT LOA a
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 ❑ 1 No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisionsbf 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. PARKING
SPACES REQ'D D PROVIDED I
' J
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE , OATE
I am exempt from the licensing'requirements as I am a
licensed architect or a registered professional engineer slz of No. OF PROM TO INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- E TING BLDG STORIES SIG ATURE
mess and Professions Code). �sfi esFINAL APPROVAL
RESENT USE OF BUILDING Z�
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS /////��f,/^
ON LOT AND USE ! �/ / ;2 p g 9-4 A
7
I hereby affirm that I am exempt from the Contractor's /l J. �/ LLL K/
License Law for the following reason (Section 7031.5, Busi- # e o e o
ness and Professions Code): NO. PARKING
L� ./ � O O~O O O O O
El I, as owner of the property, will do the work and the SPACES PROVIDED a
structure is not intended or offered for sale (Section J Q,� —8 8
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY ROP.SED USE of BUILDING
ew i f-t S
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
IZ�
I certify that I have read this application and state that the PERMIT FEE P O
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
anhereby authorize representatives of this County to,enter TOTAL FEE
u00
p e above—me boned property for inspectioq purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dat
WORKERS'COMPENSATION DECLARATION
CE 875 (11-84)
I CE 875 M I SC E L LA N EO U S APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF'LOS.ANGELES BUILDING AND SAFETY DIVISION
insufr., 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 `l
❑ L,� /,Certified copy is hereby furnished. L.-..
E ^ LOCALITY T�6/` 1 /� '
1 ` CCC v
Certified copy is filed with the county building inspection LOCALITY NEAR EST Q
department. �QY`i` CROSS sT. � � Yi�V
Date Applicant NEAREST DISTRI 7 NO. GROUP TYPE CESSED BY
CROSS ST O �O a Q� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (�J'^ �(�(�� O �/
COMPENSATION INSURANCE DESCRIPTION LOT No V7 L�J {V( BLOCK MAP HIGHWAY
NO
NO (CIRCLE) STATE MAJOR SECOND LOCAL
S.
(This section need not be completed if the work involved TRACT NOWOF BLD GON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) r USE OF
I certify that in the performance of the work-for which this SIZE of Lor 'J EXISTING BLDG. O
permit is issued, I shall not employ any person in any manner OWNER V S AU,�\Nu s-D
so as to become subject to the Workers' Compensation Laws MAIL �II�,1 1 �t -iI OCCUPANCY GROUP221 �
Date Applicant ADDRESS Gj��j �• K ITT, U
NOTICE TO APPLICANT If, after making this Certificate of CITY ���TTj`R NOLWJ
3 O 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.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION p Panic Devices
I hereby affirm that I am licensed under provisions of ChapterSAFETY PERMIT'EJ 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 infull force and e /`n SS
•
effect PARKING REQ'D =T PROVIDED
SPACES
License Number Lic Class o -e Kwoo o
LIMITED TIME USE
Contractor Date • DATE DATE
ElI am exempt from the licensing requirements as I am aFROM TO
licensed architect or a registered professional engineer SIZE of No OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING
Lic or Reg No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS a. 1 1 FEE
'ON LOT AND USE w
I hereby affirm that I am exempt from the Contractor's f
License Law for the following reason (Section 7031 5, Busi- !-i_liI_i� ii
ness and Professions Code): NO PARKING ✓/' -
SPACES PROVIDED , al
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
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 0-V
u on the above entioned property for inspection purposes
I SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ermrttee Date
WORKERS* COMPENSATION DECLARATION 200063DPw12/90 MISCELLANEOUS APPLICATION
I,hereby.affirm that ► have a certificate of consent to telt COUNTY OF LOS ANGELES 'BUILDING AND SAFETY DIVISION I�
Insure,or a certificate of Workers' Compensation Insurance, or
a certlfled'�ory thereof (See, 3800, Lab C)
Policv..No Company FOR APPLICANT TOFILL IN BUILDING
BUILDING ADDRES ADDRESS (�
❑ Certified copy Is hereby furnishede{AL �. LOCALITY
❑ Certified copy is I lied with the county building inspection CITY ZIP
department �� NEAREST
CROSS ST
Date Applicant, _ SIZE OF L1bT NO OF BLDGS NOW ON LOT DIS Np„ GRQyP TYPE cesseD By
CONST
CERTIFICATE OF EXEMPTION FROM WORKERS TRACT BLOCK LOT NO
COMPENSATION INSURANCE MAP HIGHWAY
NO (CIRCLEI STATE MAJOR SECOND LOCAL
(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 ($100) or less)
1 certify that in the performance of the work for which thispWNE TEL NO t I
IV.I. I t
permit is Issued, [ shall not employ any person m an' manner
� ADDRESS
so as to become subject to the Workers' Compensation/Ca) l--A,j 1---. W OCCUPANCY GROUP t'
Date Applicant �terulficae
CITY- \ ZIP —
NOTI O APPLICANT If, er w 0i,,Q 0� OCCUPANT LOAD
of Exemption, you should become subject to the Wo ers' APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code,you must forthwith '
comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑
irevoked
LICENSED CONTRACTORS DECLARATION occuPANcv INSPECTION❑ Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW I
9(commencing with Section 7000)of Division 3 of the Business NO OF EXITS
and Professions Code,and my license Is In full force and effect
ARCING REQ'D I PROVIDED D
License Number LIc Class ��jSPACEZf
S LJ
Contractor _ Date —_ LIMITED TIME USE
DATE DATE
❑ 1 and exempt from the licensing requirements as I am d FROM TO
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Business SIZE OF NO OF INSPECTOR'S
and Professions Code) EXISTING BLDG STORIES SIGNATURE
LIC Or Reg NO Date PRESENT USE OF BUILDING FINAL APPROVAL
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I .un exempt Irons the C'onuactoi's License
Law for the following reason (Section 70315, Business and
Professions Code) NO PARKING p�
SPACES PROVIDED t t ^
❑ 1, as owner of the property, will do the work and the V 1
structure is not Intended or offeied for sale(Section 7044, PROPOSED USE OF BUILDING
Business and Piofessions Code) n �/ (��/
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is Issued
(Sec 3097, CIV C.) PROPOSED MAX OCC
Lender's Name APPLICANT(PRINT) TEL NO
Lender's Address ADDRESS
I certify that I have read this application and state that the
above Information Is correct 1 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 I ISSUANCE FEE
the above-mentioned property for Inspection purposes
ti TOTAL FEE
7 SEE REVERSE FOR EXPLANATORY LANGUAGE
S at of P tee gate
{ i WOR-KI RS' COMPENSATIONDECLARATION xbM444
0-006LWW t 2/90 MISCELLANEOUS APPLAPPLICATION2
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES -BUILDING AND SAFETY DIVISION'
-insure or a cenifieate of Workers'Compensation Insurance, or =
a certified cop! thereof (Sed. 3800, Lab C), `
t FOR APPLICANT TO FILL IN BUILDING
Policy No- Company
BUILDING ADDRES gA ADDRESS -
❑ Certified t opy-is hereby furnished g y , LOCALITY
❑ Certified copy is filed with the county building Inspection CITY , ^ ZIP r
department l.k. �7 NEAREST
7 7 w V CROSS ST
Date _ Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY 4
CONST
CERTIFIC.,\TE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO. C
( I COMPENSATION INSURANCE NO HIGH WAV
- NO (CIRCLE) STATE MAJOR SECOND LOCAL
(This section treed not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE �7ONDITIONS fk
by the permit is for one hundred dollars ($100) or less.) C
I certify-that ui the performance of the work for which this TifY� erS/�'I ��IA) TEL
r�c�6
I permit is Issuea I shall not employ any person to any manner Gt P
so as to become subject to the Workers' Compensation Laws. ADDRLL
Ess ` OCCUPANCY GROUP a
. v .�IL.'t- w� ��Pr �ldrn, --
( Date Applicant CITY tU / ZIP
NOTICE TO APPLICANT If, after making this Certificate v gG OCCUPANT LOAD
of Exemption. you should become subject to the Workers' APPLICATION FOR
Compensation provisions of the Labor Code,you must forthwith EXIT HARDWARE
i comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowi ❑
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 Business 11 NO OF EXITS
and Professions Code,and my license is In full force and effect aIDe o ails es , fLA4&4f
�/
�
,/ v' PARKING• REO'D PROVIDED
� License Numbei Lie Class f SPACES '
i Contractor — Date LIMITED TIME USE
❑ I am exem x from the licensing requirements as I am a DATE DATE
� FROM TO
licensed architect or a registered professional engineer
acting in my professional.capacity (Section 7051, Business SIZE OF NO OF INSPECTOR'S
and Professions Code) EXISTING BLDG STORIES SIGNATURE.
LIC. or Reg NO - Date PRESENT USE OF BUILDING FINAL APPROVAL
I
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS
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, Business and
I Professions Codt)- - 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,)t PROPOSED USE
-O/FBUILDING
Business
Business ant Professions Code) V� `I
t � �
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permiv is issued
( t (Sec. 3097, Civ C)
PROPOSED MAX OCC
Lender's Name _ APP CUNT(PR/fyT) ^ 1 I TEL NO.
Lender's Address A DRESS
1 � I
I certify that I have read this application and state that the v �" �' CA
above information is correct I agree to comply with all County PERMIT FEE
I ordinances and State laws relating to building construction,and
hereby authorize representatives of this County to enter upon ISSUANCE FEE
( 1 the above-mentioned property for inspection purposes
. I TOTAL FEE
1
% I SEE REVERSE FOR EXPLANATORY LANGUAGE
Slgnatu e of Permittee Date
«(-�RK1 R5 COMPENSATION DLCt,li.,i,o• 7 8 M ISCELLANEOUS APPLICATION .
75
CE 975 111 841 -
I herebv affirm that I have a certificate of consen! to self COUNTY•OF LOS ANGE BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insuiance,or �' Y
a certified co thereof(Sec. 3800, Lab, ) 0 .
Policv NAR,
Company —�� FOR APPLICANT TO,FILL IN BUILDING
� 67"7y AD OR SS
Certified _opy is hereby furnished BUILDING - (nJ�` m �
ADOR`rr �i/W7L - LOCALITY
1 C.ertiflied Copy 1s tiled with the county budding Inspection % LOCALITY �� �r NEAREST
department CROSS ST
Date - -1p Dltuant NEAREST DISTRICT NO GROUP TYPE CESSED 3Y
CROSS ST 'Q (%/ {� CONST
r CERTIFIC ATE OF EXEMPTION FROM %MRKERS LEGAL
COMPENS-\TION INSI,R aNCE DESCRIPTION LOT No BLOCK AAP wIONW Av
' NO ICIw CL¢I STATE MAJOR SECOND LOCAL
NO OF SLOGS
(This )ection need not he completed if the ork Involved TRAC- NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit Is for one hundred doll ars iS I00) or less.) usE of
r SIZE OF,LOT SCIS T ING BLDG +
I :ertLfv that In 'he ner'ormanLC Or :Ile 'lorl, :u: '01'Cll -his
permit is issued. I ;hall not emnlol ink ce:;on n am''Wanner % OWNER
so as to become :ublect •o the %`,orkers Comoensanon Lases % RAIL OCCUP4NCY GROUP
(/�,y
AOOR ESS alJl� / -G/�Yi VNE7�C.��\✓\`� -
Date CorhCant __ %
NOTICE TO APPLIC\,,T If, .iter makir_- :his .-ertrlcate of C1, vo OCCUPaIVT LOAD
PC�rw.\ o n IIs auF- Y,tb�X367
Exemption, you ,houla become subject -o :he j%k9mers APPLICATION FOR E,<IT HARCWARE
Comoensanon oro%isions of the Laoor Coae 'ou must torth
\l Itll LomplyILII •Pt'1 n7n%lb,Ui1S 't I'll -e'IIII',Ilail 1)C -RAILER JSE 1 - GEOLOGY INSPEC-•ON -- No Spec Knowl
C deemed res n4 d — — El
LICENSED(-0`TR.aCFORS DECL \R \T'U'- occJP•ANc NSPECTION B
Panic Devices
El
I !" ,
herebv at`um ;hat I am licensed under provisions of UiaUfer a
SAFETY PERMIT ] (LIST ITEMS SELOW)
9 (commencing xith Section 0001.of Dnrsion 3 of -ire Busi- NO OF EXITS
ness and Professions lode and ms license is In 'till Ilrce and
effCLt PARKING
n 1 - SPACES
REO'D � PROVIDED
License +ur 1 e L,L Class
LIMITED TIME USE
.; (_lntral.tnr Da-', 1 DATE pA iE
2 I tm e-ei,ipt rU111 hr ILens1112 -eauue:nen,� 1 am i y
liccnsed ar:aittL: or i -eeistered -iroiesqural 'nctnee: ,IZE OF NO OF IN SPEC- R S
? actin" Ln -it orote,Sional _soja :t seL-:Cn I IS[t S- -XIS- NG 3LZG 1 STORIES SIG T E/
mess and Protesvons( ode)� — -- — FINAL APPROVAL
J Lal, or Ree No �4 E5E'IT 'JSE OF 3UILDING
a
HOME OR'\IER-RLILDCR DELL aR \CIO`. No OF EXISTING BUILDINGS
ON LO" ANO USE
I hereby affirm liat I 1,11e'.empt --nm :he Con•.*aLtor ,
LILense Ldw for :ate cllo,\mL season Se�:ion -Oil
ness and Professions Code) NO PARKING
SPACES PROVIDED
I,
is olvner of -fie oropern 'vtf do he iUtti Ind he
structure is ,ioi emended or otte:ed or lie e aon
044 Bii mess 11111 PT0le,SI1)1lSt )SCI
% PROPOSED USE OF BUILDING �e
CONSTRUCTIU\ LLVDI\G '`I;CNI-1
1 herebl dtfirm that :here is d Lonstructton lend-rig agency �Y p
for the performanLe of the work for MUL11 this permit Is r� •�»
issued(Sec 30o Cis C 1
Lender shame ----------_--- _ — I >
PROPOSED MAX OCC ' I
Lender s ldaress --
' 1
25.00
1 certtfv that I hale read this application and ta(e That tilePERMIT FEE
' - abosemf01`1113non Is correct I agree to Lolnply ••Lith 311 County ISSUANCE FEE
ordDid
nces and State lairs relating to budding construction.
and herebv authorize representatives of this Counts to enter TOTAL FEE 25.00 "��
Upon the above-mentioned propertl for mspet tion pmr oses fit:
I SEE RE%ERSE FOR EXPLANATORY LANGUAGE � .I
% % -
1
WORKERS'COMPENSATION DECLARATION i a
ICE CE 875 (11-84) M I SC E L LA N EO U`� APPLICATION
87
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 co y r of(Sec 3800,Lab.C.)., t
Policy No Company FOR APPLICANT TO FILL IN PD DR ING
ESS ���� •
PDDRESS
Certified co is hereby furnished. BUILDING A' _
copy y XX ADDRESS ,V. LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. XY" CROSS ST
Date Applicant NEAREST DISTRICT NO GROUP TYPE CESSED BY
CROSS ST. ' CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK 11AP HIGHWAY
ISO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO OF BLDGS
(This section need not be completed if the work involved TRACT NOW ON LOT IISE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE OF r
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this D'
C:)
permit is issued, I shall not employ any person in any manneXX OWNER of building
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUPZ:1
ADDRESS )---
Date Applicant C-3
NOTICE TO APPLICANT If, after making this Certificate of CITY TNoI. OCCUPANT LOAD Q0
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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 0
1 hereby affirm that I am licensed under provisions of Ciapter 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 ani
effect. Name of business FARKING
!.PACES REq•D E:= I � ROVIDED
License Number Lic. Class G
•�/� LIMITED TIME USE
�/
Contractor Date ATE D _ C
11 �- 'D _
-_ AT '
IJ I
EJ I am exempt from the licensing requirements as i am a FROM: TO
6
licensed architect or a registered professional engineer SIZE OF NO. OF
_acting m N
my professional capacity (Section 7051, Bus- 7 EXISTING BLDG. STORIES NECATTO
RAS
iness and Professions Code). t INAL APPROVAL
PRESENT USE OF BUILDING (,
Lic.or Reg No. Date
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS l�
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
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
25 - 00
above information is correct I agree to comply with all L,ounty ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 25 .00 '
u o the b ve��-m��Mip
itptioned o t for in e ion es
p
�EREVERSE
X FOR EXPLANATORY LANGUAGE
Signature of Permittee Date