HomeMy Public PortalAbout6269-6271-6273-6275 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (11-84) MISCELLANEOUS APPLICATION
t
I hpreky a certificate
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 7/ P
ADDRESS
Certified copy is hereby furnished. BUILDINGLOCALITY
ADDRESS6,271 RQ�FMI=
0 Certified copy is filed with the county build in inspection LOCALITY
NEAREST
department. CTY CROSS ST.
Date Applicant NEAREST _ DISTRICT NO///... GR UP TYPE PROCESSED BY
CROSS ST. LOQ ��T AV>: O V CONST.
CERTIFICATE OF EXEMPTION FROM W RKERS' LEGAL o
COMPENSATION INSURANC DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STA/. MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollar ($100) or less.) us OF
SIZE OF LOT EXISTING BL G.
I certify that in the performance of the ork for which this
permit is issued, I shall not employ any rson in any manner OWNER
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP o
MAIL /��/y�
"(Jm I � U
Date ADDRESS Applicant - L„
lk
TEL. y OCCUPANT LOA D_
NOTICE TO APPLICANT: If, after king this Certificate of CITY (�� Nolii v,
Exemption, you should become bject to the Workers' z
Compensation provisions of the La or Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provrsio or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec. Howl.
deemed revoked. Panic De ices
LICENSED CONTRACT RS DECLARATION OCCUPANCY INSPECTIO
I hereby affirm that I am licen d under provisions of Chapter
9 (commencing with Section 7 00) of Division 3 of the Busi- SAFETY PERMIT (LIST ITEMS BELOW) NO. OF XITS
ness and Professions Code,a my license is in full force and I'
effect. U PARKING R./-
License
E 'D PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
El I am exempt fro the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my pr essional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Profess* ns Code). FINAL PPROVAL -r��
PRESENT USE OF BUILDING `
Lic.or Reg.No. Date
HOME O NER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 1� _ := r �,
ON LOT AND USE
I hereby affir that I am exempt from the Contractor's b
License Law fo the following reason (Section 7031.5, Busi-
ness
usi �( Y/ -; ;-,
ness and Profe ions Code): /� - `u- :U- - _
NO. PARKING 1 n/� a:•�: -'
SPACES PROVIDED U\
I, as ow er of the property, will do the work and the -r { =, _ -;
structur is not intended or offered for sale (Section
7044, usiness and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I IJa
I hereby ffirm that there is a construction lending agency
for the erformance of the work for which this permit is
issued( c. 3097,Civ.C.).
Lender' Name
PROPOSED MAX. OCC.
Lender' 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 thea entioned property for inspecti n purposes.
f� ,_ 7 `X SEE REVERSE FOR EXPLANATORY LANGUAGE
S• nature of PermitteV Date
WORKERS'COMPENSATION DECLARATION. CE 875(2-80) 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 APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. uILDINGLocwLlTv
❑ ADDRESS LPN
Certified copy is filed with the county building inspection NEAREST
department. o ALITY 7 rl
� CROSS Sr.
Date Applicant EAREST 1/� DISTRICT O. G, O TYPE ]77D BY
CROSS ST. ,C�LJ -� 4 !'' CONST
ID
CERTIFICATE OF EXEMPTION FROM WORKERS', LEGAL v ( IJ
DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE
COMPENSATION INSURANCE STATE MAJOR SECOND LOCAL d
NO. OF SLOGS. NO. (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O
by the .permit is for one hundred dollars ($100) or less.)
USE OF'
SIZE F'LOT EXISTING BLDG., Ir
I certify that in the performance of the work for which this 0
permit is.issued, I shall not employ any person in any manner' M
so as to become subject to the Workers' Compensation Laws. n LER , tr7r'T! _:OCCUPANCY GROUP U
UJ
Date ApplicantAD RESS 18 V . EhR N
NOTICE TO APPLICANT: If, after making this Certificate of CITY S/7 E/jy+ rTEL 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 O GEOLOGY INSPECTION'❑ NO Spec. Know]. ❑
deemed revoked. Panic Devices ❑
LICENSED CONTRACTORS DECLARATION occuvarvcv INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) No. of Exlrs
❑
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect. PARKINGSPACES REQ'D PROVIDED
License Number Lic.Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
El
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). j^ FINAL APPROVAL
RESENT USE,OF BUILDING
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
usi ness and Professions Code): NO. PARKING
SPACES PROVIDED •�--�x
❑ I, as owner of the property,will do the work and the U
structure is not intended or offered for sale (Section f� I�6
7044, Business and Professions Code _ /
' PROPOSED USE OF BUILDING /�O n
CONSTRUCTION LENDING AGENCY v K
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 ter ' at I have read this application and state that the
abo e infor ation is correct. I agree to comply with all County ISSUANCE FEE
or mantes nd State laws relating to building construction, . TOTAL Fee
an, he ere resentatives of this County to enter
U 51 a mentioned property for inspec 'onurs. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
�i
WOR KERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hItreby 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 / .
-71
ADDRESS �[,!
Certified copy is hereby furnished. ADDREILDING M
SS ./"9I ♦ /Q QSCE—Ab BLVy. , e1 LOCALITY
' 17a5 .!
EJ Certified copy is,filed with the county building inspection1. NEAREST
department. LOCALITY CROSS ST.
Date Applicant EAR. ��I/i^ /`O DISTRICT N IG TYPE IPROCE BY
CROSS ST. �t!(�v , CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL VVV/// ��(///
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND OCAL a.
NO. OF BLDG S.
(This section need not be completed if the work involved TRACT NOW ON LOT USEE�CCU
CIAL CONDITIONS 0
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. t/ cc
I certify that in the performance of the work for which O
permit is issued, I shall not employ any,person in any OWNER ��. �� f-
so as to become subject to the Workers' Compe s. AIL NCY GpRRO/UP W
ADDRESS l�D /T� 0-
.Date—
.Date Applicant �i zDab TEL.NOTICE TO APPLICANT: If, after making thI icate of cITY OA�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. Panic Devices ElLICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that 1.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 PARKING
effect. SPACES REO'D 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 S NATURE
inesS and Professions Code). PRESENT USE OF-BUILDING FINAL APPROVAL _
Lic.or Reg.No. Date ^ r
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON NO:
AND USE 24 5 2 7 A
I hereby affirm .that, I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- # G - 88
ness and Professions Code): NO.PARKING
SPACES PROVIDED
I, as owner of the property, will do the work and the o a 6 • • o •
structure is not intended or offered for sale (Section r Q 2 Li 8 6
7044, Business and Professions Code).
' X-00--s–ED USE OF BUILDING
CONSTRUCTION LENDING AGENCY yJ
I hereby affirm that there is a construction lending agency s*ug F
/L'iolo
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, TOTAL FEE
' and he au Ize r resentatives of this County to enter
upo the b e-mentio d property for inspection pyrposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permiltee `/Datel
li
WORKERS'COMPENSATION DECLARATION CE 876(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have' certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'
rs'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING /'
ADDRESS (Q� J SJ LO CALITYT J
F Certified copy is filed with the county building inspection LOCALITY ' V /� NEAREST
i I
department. 7 o CROSS ST.
Date Applicant NEAREST { ®� / DIS RICT NO. G OUP TYPES PRO ED BY
CROSS ST. L �•`/D ' ^ CONST. ./T
CERTIFICATE OF EXEMPTION FROM WOR S' LEGAL ^uGl �---�
COMPENSATION INSURANCE; DESCRIPTION LOT NO. BLOCK MAP '!IR LEj STATE MAJOR SECOND LOCAL
NO.
NO. OF BLDGS.
(This section need not be completed if the rk involved TRACT NOW ON LOT- Use ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars 00) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
G f
I certify that in the performance of the for which this
permit is issued, I shall not employ any
F/
in any manner OWNER Ad
S v
so as to become subject to the Workers' mpensation Laws. OCCUPANCY GROUPi I=MAIL
ADDRESS U V
�l
Date Applicant u,
TEL' OCCUPANT LOAD
NOTICE TO APPLICANT: If, after ing this Certificate of CITY �J/C� No. 7 — Z
Exemption, you should become ject to the Workers'
Compensation provisions of the L r Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisi or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Know].
deemed revoked.
LICENSED CONTRA RS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am lic ed under provisions of Chapter SAFETY PERMIT LIST ITEMS BELOW)
9 (commencing with Sectio 000) of Division 3 of the Busi- No. OF EXITS
ness and Professions Code, d my license is in full force and
effect. PARKING REQ�D PROVIDED
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
I am exemle
the licensing requirements as I am a
licensed arr a registered professional engineer SIZE OF No. of IN PE CTOR'
acting m ssional capacity (Section 7051, Bus- EXISTING BLDG. STORIESNATURinessandPCode). FINAL APPROVAL
PRESENT USE OF BUILDING /Lic.or Reg.No. Date !lHOME 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- 7 7
ness and Professions Code): NO. PARKING 001010-00041 �1 �; 9LI
I, as owner of the property, will do the work and the SPACES PROVIDED 0474 1 AM ;ac-g
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING tVR�
I hereby affirm that there is a construction lending agencykq r ;.
for the performance of the work for which this permit is -
t
issued(Sec. 3097,Civ.C.).
Lender's Name t
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the
above information is correct.1 agree to comply with all County ISSUANCE FEE (1\
ordinances and State laws relating to building construction, /
and hereby authorize representatives of this County to enter TOTAL FEE 2 �lJl
upon Ae above-mention property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitte Date
WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C AT I O N
o
1 hereljaffirm 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.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
FICertified copy is hereby furnished. BUILDING /J /
ADDRESS �L ( RQ SOZ_412�a-�L LOCALITY C G�
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. �/ G Gid ! �//O CROSS ST.
Date Applicant NEAREST DISTR T N G OUP YPE PROC SS BY
CROSS ST. Lo dem �c, /` P-N.T,/)
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALst v
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MMAJOROJ 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 ($100) or less.) USE OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. >.:/ o
permit is issued, I shall not employ any person in any manner OWNER 2LUjA/
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP
ADDRESS 6Z? �t p5��+- !lIJJJ v U
Date Applicant (( / 47
NOTICE TO APPLICANT: If, after making this Certificate of CITY Vie,, (e C& rTio.l$(�2gS— 1 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
El
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 D PROVIDED
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 INSPECTORS
acting in my professional capacity (Section 7051, Bus XISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL "
Lie.or Reg.No. Date e
PRESENT USE OF BUILDING J
��.
.S'u �os e/'�oayt! CLo�! Re Pai L s�4
HOME OWNER-BUILDER DECLARATION NO. OF EXISTIreG BUILDINGS 8 5 2 6 AA
ON LOT AND USE # • O • • 88
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 CES PROVIDED a O D O • •,•
EJ1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section 1 2.o6 8 7
7044,Business and Professions Code):
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING �/1
I hereby affirm that there is a construction lending agency �l/�Ve �j pca r01! G(��1��ri, KR Y",(. r 5a (-5
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
upo the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
V..
10—Z6—e7_
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION CE 876(2-80) MISCELLANEOUS APPLICATION.
hereby affirm that I have certificate of consent to self
insure, 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 BUILDING
ADDRESS I
Certified copy is hereby furnished. ADDLRESs Fj 7� LOCALITY
Certified copy is filed With the county building inspection r_ /// [1� NEAREST
department. L CALITY -Ten �` /� G� ` ��-��JJ CROSS ST.
Date Applicant NEAREST 'C•• 6' (/ (J DISTRICT NO. GROUP I TYPE PROCESSED BY
CROSS ST. L-0/7 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY }
STATE MAJOR SECOND LOCAL d
NO. OF BLDGS. NO. (CIRCLE)
(This SOCtIOn need not be completed if the Work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars ($100) or less.)
USE OF
SIZE OF LOT EXISTING BLDG. - t�
1 certify that in the performance of the work for which this 0
permit is issued, I shall not employ any person in any manner WNER �j� e/ ,; U
so as to become subject to the Workers' Compensation Laws. AIL ' r OCCUPANCY GROUP W
• AD RESS / .�. t3.
Date Applicant ¢ N
NOTICE TO APPLICANT: If, after making this Certificate of CITv C �a�1 OCCUPANT LOAD z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with, such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION
deemed revoked. ❑ No Spec. Knowl. ❑❑
LICENSE -CONTRACTORS DECLA RATION- - _______occuPwrvcv INSPECTION��
Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (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 PARKING. r�
effect. SPACES REQ'D U PROVIDED
'
License Number Lic.Class
_ - LIMITED TIME USE
Contractor Date DATE DATE
aFROM: 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 SYGNATURE
iness and Professions Code). ESENT uSE OF BUILDING FINAL APPROVAL /
Lic.or Reg.No. Date r
NO. OF EXISTING BUILDINGS
HOME OWNER-BUILDER DECLARATION
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's G
License Law for the following reason (Section 7031,.5, Busi- 3176
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 n l
7044, Business and Professions Code). ROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY (((
I hereby affirm that there is a construction lending agency P
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 C
ordinances and State laws relating to building construction, TOTAL FEE V
and hereby authorize representatives of this County to enter
upo "the above-mention property f inspec 'on purposes. `SEE REVERSE FOR EXPLANATORY LANGUAGE
5iinature of'Permittee Date
' I i WORKERS' C0MYbN6A11VlV 1JCI.LHtCH11vtV
20;0663DPWI2/90 LL.f ,I1tjzV 7 l'Hii—fL1l -�CkIt A%-/lY n,.•
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,Wdikers' Compensation Insurance,or
a Certified copy thereof.(Seca 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
•' UIL NG ADDRESS - ADDRESS
❑ Certified copy.is'.hereby:furnished. $` Z Z Uci LOCALITY
❑ Certified copy is filed with the county building inspecti ITY zip
department. NEAREST
/ r 77 gd CROSS ST.
Date Applicant SIZE OF LO NO.OF BLOGS.NOW ON LOT DIS_TRICTNO. GROUP TYPE PROCESSED BY
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT No. consr. O
I COMPENSATION INSURANCE MAP HIGHWAY V
' NO. (CIRCLE) STATE MAJOR SECOND LOCAL..
(This section need not.be completed if the work involved ASSESSOR MAP BOOK "PAGEPARCELby the permit is for one hundred dollars WIN) or less.) tisE zoNE SPECIAL CON 4ITIONS
0
certify that in.the performance.of the work for which th' r er O. "��� w
permit is issued;I shall not employ any person in any man G
so as to become subject to the Workers' Compensation La AD! �p r y ZJ� OCCUPANCY GROUP o
i Date Applicant , CITY - _ zIP O(2dJ�
NOTICE TO APPLICANT: If; after making this Certificate -1-11E / OCCUPANT LOAD
of Exemption, you should become subject to the Workers' APPLICATION FOR
Compensation provisions of the-Labor Code.you must forthwith EXIT HARDWARE:
comply With such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ NO Spec.Knowl. ❑
revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY 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 Busines NO.OF EXITS
and Professions Code,and my license is in.full force and effect -ftne ot Busi-ness
REWD 1 1 PROVIDED
PARKING• .
License Number Lic. Class ,�/,' , S�o�P SPACES =
i Contractor Date 7 LIMITED TIME USE
i ❑ I am'exempt.from the licensing requirements as I am a DATE DATE
licensed.architect or a registered professional engineer FROM: To:
acting in my professional capacity (Section 7051, Business SIZE OF NO.OF INSPECTOR'S
1
and Professions Code). EXISTING BLDG. STORIES .SIGNATURE..
Lit or.Reg. No. Date PRESENT USE OF BUILDING FINAL APPROVAL , OZ
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, Business and
Professions Code): NO.tROPOSED
PAR ACES P oviDED.
El I, as owner. of the property, will do the work and th
structure is not intended or offered for sale(Section 704 USE OF BUILDING
Business and Professions Code).
I CONSTRUCTION LENDING AGENCY
j I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
I (Sec. 3097, CIV. C.).. PROPOSED MAX.OCG
iLender's Name PLICANT INT) TEL NO.
o,. 77(—
Lender's Address DRESS
I certify that I have read this application and statethat the r �� a o G
above information is correct. I agree to comply with all County
I PERMIT FEE , ,
ordinances and State laws ielating to building,construction,and 1
hereby authorize representatives.of this County to enter upon ISSUANCE FEE I
the above-mentioned property for inspection purposes.
.. •'
TOTAL FEE
177/0Z SEE REVERSE.FOR EXPLANATORY LANGUAGE
Sienature of Pen mee Date
WORKERS'COMPENSATIONDECLARAT[ON 76M444 MISCELLANEOUSAP�LICATION
1 hereby affirm that CE 875 (11-84)► 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 6ertified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILD IN
/,/ NL:HESS //41
FICertified copy is hereby furnished. XX .1111.D.111,
REV L S � LOCALITY
El Certified copy is filed with the county building inspection IL NEAREST
department. xy, CROSS ST.
Date Applicant NEAREST Lai, DISTRI NO. GROUP TYPE CE SE BY
CROSS ST. � /( O p CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (�
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAF HIGHWAY
NO. (CIRCL¢) 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
ISIZE OF LOT /2 0G EXISTING BLDG. Or
1 certify that in the performance of the work for which this , 0-,
permit is issued, I shall not employ any person in any manneXX OWNER of building 14ttr�ie ���/air ® Z__�
so as to become subject to the Workers' Compensation Laws. n' / , OCCUPANCY GROUP n-_
I MAIL ADDRESS I N` )?OSv PuJG P/'I GI 61 ���0 CJ
Date Applicant 1 yp I",
NOTICE TO APPLICANT: If, after making this Certificate of clrY n�S�/)Cn/y T. OCCUPANT UO7� OCCUPANT LOAD C�
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
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 a
effect. X (Name of business PARKING SPACES REQ'D PROVIDED OVIDED
License Number Lic. Class I �
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 LSIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- ,EXISTING BLDG. STORIES SIG TORE
inessand Professions Code). FINAL. APPROVAL
-PR ESENT USE OF BUILDING �_
Lic.or Reg. No. Date ly
'a
HOME OWNER-BUILDER DECLARATIONEXISTING BUILDINGS ( ��. 's+ ,r. E•)I••r<<.- t`
ON LOT AND USE
I hereby affirm that 1 am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
1, as owner of the property, will do the work and the Ig=PACES 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 i
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 25. 00
above information is correct. I agree to comply with all County. 1 ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter I`TOTAL FEE 25 -00
upon the above-mentione property for inspection purposes.
XX / XX / q7 SEE REVERSE FOR EXPLANATORY LANGUAGE
Gtr'
' Signature of Permitlec Date
>! WORKERS'COMPENSATION DECLARATION CE 875 111-841
• CE 875 MISCELLANEOUS APPLICATION
nsii:-evy'affert 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 ce_tified copy thereof(Sec. 3800,Lab.C.).
7[—J Policy AD
No. Company FOR APPLICANT TO FILL IN DR IESSSS
ADDR
Certified copy is hereby furnished. BUILDING RESS LOCALITY
ADD6275
I
Certified copy 15 filed with the county building inspection LOCALITYTeNEAREST
department. mple City CROSS ST.
Date Applicant NEAREST LOW )Z7/4/
DISTRICT NNO.J G 6p TYPE P CESSED BY
CROSS ST. v lIJAJAGG /v�1{ CONST.
I CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NAP RICHw Av
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLD GS.
(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 (5100) or less.) uSE of
SIZE OF LOT EXISTING BLDG. }
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner O INNER T IIC
so as to become subject to the Workers' Compensation Laws. M ILQ n �/��� OCCUPANCY GROUP
I Date Applicant ADDRESS 1��N' �Q J�EA�`•`�+`[�1 ` JJ
NOTICE TO APPLICANT: If, after making this Certificate of c� 74 S 2 82
CITY voL OCCUPANT LOAD =
�ri�— 9 1
Exemption. you should become subject to the Workers' _
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
i with comply with such provisions or tats permit shall be TRAILER. JSE GEOLOGY INSPECTION ' e
deemed revoked. — — No Spec. Know!.
OCCUPANCY INSPECTION$$ Panic Devices
LICENSED CONTRACTORS DECLARATION L_
1 hereby affirm that I am licensed under provisions of Chapter (L
SAFETY PERMIT — s- ITEMS aEiOr.)
! 9 icommencine with Section ?000) of Division 3 of the Busi- — NO. OF EXITS
ness and Professions Code. and my license is in full force and
effect. ( � Lei
v; I REO D (--.J I PROVIDED
SPAC
License `umber L:c. Class j
LIMITED TIME USE
Contractor Date C TE ❑ATE
w
Z - FRO1+1: TC:
1 am exempt from the iicensing requirements as I am _
i licensed architect or a registered professional en_inee: SIZE OF !NZ. O- INSPECTOR
actinir in my professional capacitn Se ion 7051. Bus EXISTING aLOG. S-ORI_-
SIG TU RE
s inessand Professions lCodei. FINAL APPROVAL
PRESENT USE OF BUILDING 1
Lic.or Reg. No. Date ) vV
- 1
HOME OWNER-BUILDER DECL.\R.i'710N NO. OF EXISTING BUILDINGS
ON LOT AND USE I / / _ i•-- r-
1 hereby affirm that l am exempt from the Contractors i Lp �!��:3_i-'!I'•=l_`.i-'� -`i '•_
I License Law for the followin_ reason (Section '031.5, Busi-
ness
usi ness and Professions Code): NO. PARKING
1, as owner of the property. will do ;he work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY g PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending asencv
t I for the performance of the work for whish this permit is
issued(Sec. 3097,Civ.C.(.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I I certify that I have read this application and state that the r RMIT FEE 25.00
above information is correct. I agree to comply with all County ISSUANCE FEE
o!:dinances and State laws relating to building construction.
aild hereby authorize representatives of this County to enter TOTAL FEE 25.00
upon the above-mentioned prope y for inspection purposes.
t I SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa re of Pefm-'Z�e`f Date
i WORKERS'COMPENSATION DECLARATION 7E8751ti8a) MISCELLANEOUSAPPLICATION
1 hereby r. affem that I have certificate of consent tsere COUNTY OF LOS .ANGELES 'BUILDING AND SAFETY DIVISION
insu ^, or a certificate of Workers'
rs'Compensation Insurance,
e,or
l a certified copy thereof(Sec. 3800, Lab.C.). `
Policy No. Company FOR APPLICANT TO Fl LL IN Ell ING
ADDRESS •���"
Certified copy is hereby furnislied. Bu1LDING
—DRESS 07: LOCALITY
1 F1 Certified copy is tiled with the county building inspection LOCALITY NEAREST
department. Temple City C.:OSS ST.
Date Applicant NEAREST DISTRI T NO. GROUP TYPE �CESSED BY
pp cRoss D fi ICONs
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK {rnaa HIGHWAY STATE MAJOR SECOND LOCAL
NC. ICIRCLEI
i
INC. OF SLOGS.
(This section need not be completed If the work involved iTRAC7 INON CN LOT iU_,E ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (S100) or less.)
USE OF
I SIZE OF LOT I EXISTING BLDG 1
I certify that in the performance of the work for which this nn
permit is issued. I shall nor employ any person in any manner O}YINNERf VIA P AN
so as to become subject to -lie Workers"Compensation Laws. "AILCRESS OCCUPANCY GROUP g—
{ AD -_ —
Date Applicant �� � � _
NOTICE TO APPLICANT: if, liter making this Certificate of CIT rac OCCUPANT LOAD
Exemption, you should become subject to the Workers I
Compensation provisions of the Labor Code, you must forth APPLICATION PGR EX HARDNIARE: !
with comply with such provisions or this permit shall be TRAILER USE EO LOGY IN=_PEcreN c
deemed revoked. i ` IJ No Spec. Knolwl.
OCCL:PANC`.' iNSPECTICN$g °anic Devices I
LICENSED CONTRACTORS DECLARATION 1 I L_
I herebv affirm that I am licensed under provisions of Chapter —
SAFETY PERMIT _I, {LIST ITEMS 3E LO'.Yi
9 (commencing with Section '000) of Division 3 of the Busr NO. of EXITS
ness and Professions Code, and in license is in fall force and
effect. / PERKING
SPACES REO'D PROVIDED
�n 11��JJ
T_ License Number tic. Class LIMITED TIME USE
•.`�'n Contractor Date DATE DATE
Z I FROM:
Z
ti I am exempt from the licensing requirements as I am a TO:
licensed architect or a registered professional engineer SIZE OF No. OF INSPECTOR'S
Z acting In my professional CaDaciiy ;Secilon /051. Bus- EXISTING BLDG, STORIES S ATUR
C
a iness and Professions Code).
PRESENT USE OF BUILDING !NAL APPROVAL
Lic.or Res. No. Date—
HOME
ate GZ 2
l ' ( /
EtO�'IE OWNER-BUILDER DECLARATION I No. of EXISTING BUILDINGS /nnj F441 F�`�
ON LOT AND USE It-on
L�. L Aft;
I herebv affirm that I am exempt froth the Contractor's
i:�!�'',it3 I
I License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
I, as owner of the property, will thSPACES PROVIDED _e work and the
stricture is not intended of offered nor sale (Section
I 7044.Business and Professions Code).
CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency
1 for the performance of the work for which This permit i.s
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC,
Lender's Address
I certify that I have read this application and state that the PERMIT FEE 25,00
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 25.00
1, upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
v '
Signature of Permittee Date
WORSERS'CObfPENSATION DECLARATION
CE 875 171-841 MISCELLANEOUS APPLICATION
• CE 875
I )c.-oylaiiirm 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.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS
Certified copy is hereby furnished. X BUILDING OSSa / '1 LOC'.ALITY
AD DR E S S (y-4X v lJ�
Certified copy is filed with the county building inspection NEAREST
LOCALITY
department. Temple City CROSS ST.
Date Applicant NEAREST D14TR T N9QQ. GR P TYPE ESSED BY
CROSS ST. D (/ COrF
1 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL D
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP R16NW AV STATE MAJOR SECOND LOCAL
No. (CIRCLE)
NO. OF SLOGS.
(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 (S100) or less.) USE OF
I certify that in the performance of the work for which this SIZE of Lor EXISTING BLDG. C_
permit is issued, I shall not employ any person in any manner O W N ER l` Cs. h j �, o-4—
IBJ
so as to become subject to the Workers' Compensation Laws. MAIL ( OCCUPANCY GROUP
ADDRESS ` 0 S'e,V n
I Date .applicant
rEL.
NOTICE TO APPLICANT: If, after making this Certificate of OCCUPANT LOAD CITY � c�5o,,�,.a,,,�y0. ��S- l���
Exemption, you should become subject to the Workers' APPLICATION FOR .,X IT HARDWARE:
Compensation provisions of the Labor Code, you must forth- �--
I with comply with such provisions or this permit shall be TRAILER. USE GEOLOGY INSPECTION _ IVO Spec. Know(. I
deemed revoked. —
LICENSED CONTRACTORS DECL.aR.�TION OCCUPANCY INSPECTION$$ Fanic Devices n
I lterebv affirm that I am licensed under provisions of Chapter
n 9 ICOmmenCin_ with Section 000) of Division 3 of the Busi- SAFETY PERMIT )LIST IT E.`•15 BE LOV:)
0 7 NO, OF EXITS
tiL��
ness and Professions Code, and my license is in full force and
't1CCt. c SPCESG RED I i PROVIDED
SPACES
License Number. Ltc. Class j
LIMITED TIME USE
Contractor Date DgT4 DATE
w
z - Tc: f
1 am exempt from the licensing -equiremenis as 1 am 1
INSPECTOR•
t licensed architect or a registered :+ro*essional emmnee: SIZE OF NC. O SIG NATU E
acting in my professional .apacin ISe'.:tlon -0=I Bus- EXISTING BLDG. iSTORIES
2 mess Ind Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Ree. No. Date
HOME OWNER-BUILDER DECL.aR.,;
lUN NO. OF EXISTING BUILDINGS r~
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor`;
License Law for the following reason (Section -031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED �\
1, as owner of the property. will do the stork and the
structure is not intended or offered for sale (Section
1 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING
I lterebv affirm that there is a construction lending agency �� S
t ) for the performance of the work for which this permit is
issued(See. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE 25.00
above information is correct. I agree to comply with all County ISSUANCE FEE
t ordinances and State laws relating to building construction,
and herebv authorize representatives of this County to enter TOTAL FEE 25.00
t. ) upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
v
Signature of Permittee Date
DLCLAR.-�_11"ON .7�Vi A 4
hereby affirm that I I have.a certificate of ::onscnt t;. seL CE 077 'It 84� L A N LE i..j S) Ar P L I C A T`10 N
insure. or a certificate of Workers'Compensation Insuran,:c.or CO�I_JJNTV Jk: LOS ANGEL—H BUILDING ."%NE SAFETY DIVISION
a certified copy thereof i Sec. 1800. Lit).C.).
Policv, No.__.—Coilinam,
FOR APPLICANT TO r!LL IN UILD ING
ADDRESS
L7 Certified copy is hereby furnished. X LOCALITY
A. r
SS 1(2;2.7 A/
t._�Zon.e
Certified �opy is tiled,with the counts buiidinL inspt clioll 0 NEAREST department. LOCALITY Temple City CROSS ST.
Date___Appli.--ant NEAREST _PISTRICT NO_ .:X IT'PE rC'ESSED By
CER F[F'l(..VFE OF EXEMPTION I-RoNt '.WiRKEIZS CROSS ST. CONST.
LEGAL L
COMPENSATION' INS(RANCH OrSCRIPT!ON LOT '40. SLOCK
STATE MAJOR SECOND LOCAL
IND- OF 3LDG5.
(This section need not he completed if the „otk involved i TRaCT NOW ON LOT iuse TONE SPECIAL CONDITIONS
by the permit is for one hundred doll:urs iSI001 or less.) r
77fSIC- !USE OF
OF LOT EXISTING BLDG.
I �ertify that in :lm performance >f -,he ,orl: 111C.1 PLaver ty—.
permit is issued. I shall :10-L "mploy ariv ne-,scn in am'Tininner OWNER
so as to b*ecome Sul :o the 1Vork-e1s`(_.)!nnensation M C, A 'C',V1
'A A I L OCCUPANIC':' i3ROUP
ADDRESS JV_ E,-< I 'd _j
.7.
Date____ applicant
7EL.
NOTICE To APPLICANT: lf. iii-er nnak;m: '_'tis X1 CIT C4_ N 0. H? 0 OCCUPcN_ LCAC
Exemption. voit ;iionld become tui err7,? 'lie ��,,rk- 16 1=4
APOLICA71C',, r-1;1.1_�P
(_0111POT1.1"Vion nro%ision.s i)i rlic )de. vou must :.,11-
\vitll coill:ii% 'xiiii '11ch nrmis:on� Or iii.� -cmir i!�:dl he NO Soec. <:1C,-vi.
deemed
JC:CJPANC'f ;NSPEC�'ION P311;c Devir-s
Ll� ENSED COM R.I(:TORS Dl-',.-L-�RA-1101
Ihereby affirm :har I arn 'icensed unde--rc%isionso;_(.-aptcr SAFETY PERMIT (LIST ITEMS BELOW)
9 tcominencinL %,iih Section '70001 of Division : )I ;Ile Bust- NO. OF EXITS
ness and Pi'1)10ssWrll ('0111'. Mid nn' !iCL':lSC i 111 :I:il ;0TLL' ITILI
effec". PARKING
-SPACES
License Numhcr L:c. (.-!a s
LIMITED TIME USE
ti ontr-actor DATE .A-1:
0 [ .1111 exempt :7olIl iicLmsm -euuuements :is I ant I
licensed architect Or ',I p7nfessiollal en NSPECTOR'S
..ineer �IZE OF -D.
z acriri,_� ;n :11%- rrot%, ional -1151, Bu,;- N 1ST;NS L CG. i T.0 PolE SIGNATURE
iness un:i 1'701%_'SSICII. t)de). FINAL APPROV A
"R ESENT USE OF BUILDING L
)r Pe--.
110%11-- 01%NFR-lfl_,ILDER DECLAR.MoN NO. OF EXISTING BUILDINGSU
ON LOT AND USE A
I hereby of firm that I iin exempt from the Contmctor's
License La\% for the followim-, reason (Section _031.�. Busi-
ness and P7ofessions Code): NO. PARKING
1, as ok%ner of the property. ,till do :he work and the SPACES PROVIDED
structure is not intended or offered tor :ale (Section
7044. liii,;iiie,s and Professions Code).
X PROPOSED USE OF BUILDING
CONSTRUCTION LENDING A(.',I_N(*';
herebv affirmI hat there is a construction !ending a:icncy
I :
for the performance Of the t%ork for which rhis
issued I Sec. 3()97.Civ. • -.F.
----
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE 25.00 l-'D
I certify that I have read this application and state th,..t the -D
above information is correct. I a2ree to comply with all County ISSUANCE FEE I--, ill
ordinances and State lays relatinti to buildinL co nstri,_,tion
and licrebv authorize representatives of this County tc, enter TOTAL- FEE
25.00
upon th- i rb W-mentioned propert% for inspection purpo.-,es. — 0,
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sienature or-
WORKERS' CUMYh1vJAilUN 1JCI.L1kKA11ULN 20-0063DPW'2/90 1Ki..l�L.GLLH11iCVV� Hrt'6..tvlla .tv:t!
I hereby affirm that I have..a certificate of consent to self COUNTY OF LO 'ANGELES BUILDING: AND SAFETY DIVISION
{
;insureor a certificate of.Wofkers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab.C.)
I
Policy'No. Company FOR APPLICANT TO FILL IN BUILDING GG!!
• BUILDING ADDRESS 'ADDRESS � A)
' ROJ U
❑ Certified copy.is-hereby;furnished. %` 2 ( ROSE E LVA L6CALITY Tr G. T
❑ Certified copy is filed with the county building inspection CITY ZIP
department. r�+, NEAREST. �Q A'
Iv C / GROSS ST. 'V
Date Applicant - SIZE OF LOTNO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY
90 g-11, CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT bLOCKLOT NO. O
COMPENSATION INSURANCE �2, � MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL..
(This Section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL
by the permit is for one hundred dollars ($100) or less.) USE ZONE SPECIAL CONDITIONS 0
r_
I.certify that in the performance.of the work for which this =rt:rfy Owner i TEL No. ' w
permit is issued,'i shall not employ any person in any manner a,
I so as to become subject to the Workers' Compensation Laws. ADDRESS OCCUPANCY GROUP tn
Z
Date Applicant . CITYS � ZIP r
NOTICE TO APPLICANT: If. after making this Certificate OCCUPANT LOAD
of Exemption. you should become subject to the Workers' APPLICATION FOR
Compensation provisions.of the.Labor Code,you must forthwith EXIT HARDWARE:
comply with such provisions OI'this permit shall be deemed TRAILER USE prr��777 GEOLOGY INSPECTION❑ No Spec.Know[. ❑
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 NO.OF EXITS
and Professions Code,and my license is in.full force and effect. .. ame ot Bustness
PARKING• REO'D I 1 PROVIDED
License Number Lic. Class F- L SPACES L_ J
Contractor Date _ r LIMITED TIME USE
I
❑ I am exempt.from the licensing requirements as I am a DATE DATE
licensed.architect or a registered professional engineer FROM: To:
acting in my professional capacity (Section 7051,Business SIZE OF NO.OF INSPECTOR'S
and PIOfe$$IOnS Code). EXISTING BLDG. O �''•� STORIES .SIGNATURE.
Lic. or Reg. No. - Date PRESENT USE OF BUILDING �t I V E�O�S FINAL APPROVAL
lav-r N r-o MAV V
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ���� M'
I
ONLOTAND USE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and UF_: T /4 -CHECA S
Professions Code): SPACESPROVIDED. C
i ❑ I, as owner.of the property, will do the work and the
structure is not intended or offered for sale (Section 7044_X PROPOSED USE OF BUILDING
Business and Professions Code).
I
I CONSTRUCTION LENDING AGENCY
j 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)
Lender's Address ADDRESS / q ,
I certify that I have read this application and state that the C r�4WE- ZlJ �� — 1 _0
above information is correct. I agree to comply with all County PERMIT FEE
ordinances and State laws relating to building construction,arid
�..
I hereby authorize representatives.of this County to enter upon ISSUANCE FEE
the above-mentioned property for inspection purposes.
h,s
TOTAL FEE
% p Q- X003 SEE REVERSE.FOR EXPLANATORY LANGUAGE
lure of Permittee I Date
WORKERS'COMPENSATIONDECLARATION CE8454(1t 84) M ISCELLANEOUS APPLICATION
1 hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES EUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,er
a certified copy thereof(Sec. 3800,Lab.C.). BUILDING_
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS OI SS .y�/
ADDRESS
F] Certified copy is hereby furnished. BUILDING P � �w rIT
ALY
XX ADDRESS
El Certified copy is filed with the county building inspection LOCALITY
NSAFtEST
department. CROSS ST.
Date Applicant _ NEAREST 1 DISTRICT NO. GyjJUP ITYPE ESSED BY
CROSS ST. t/(f /y� {� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL lyl7 (f FL7/
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work Involved TRACT NOW ON LOT USE 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 _� °o
permit is issued, I shall not employ any person in any manueXX OWNER of building MdaTI I"
so as t IbpeQom�e subject to the W ers' om ron ws' MAIL OCCUPANCY GROUP
Date�L(Z�-L! Applicant _ ADDRESS l�j�(��y��, �T�� j(�� [;�E] —
, —
NOTICE TO APPLICANT: If, < er making is Certificate of CITYP�sZ Vrin�A No. 6pg) OCCUPANT LOAD yr
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec. Know].
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- n � NO. OF EXITS
enessffect.
and Professions Code, and my license is in full force aIx. a
Name of business I ( N012
effect. PARKING REQ'D D PROVIDED
SPACES
License Number Lic. Class —
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSP To R'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI A RE
iness and Professions Code).
FINAL APPROVAL
Lic.or Keg.No. Date
PRESENT USE OF BUILDING
— i
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS i.;i,j.
I hereby affirm that I am exempt from the Contractor's ON LOT AND USE IY`
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
0 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
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
25- 00
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
itand hereby authorize representatives of this County to enter TOTAL FEE 25.00
upon the above-me ioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
XX �- X
Signat'. ennitt_ Date