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CE 875 '1 l 841 MISCELLANEOUS APPLICATION 1-7
' CE 875
1 hereby a cern that I have a certificate of consent to self
In COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
sure, or a ceruWorkers of orkers Compensation lnsur.ince.or
NOD)NOD) a certtfied`ccco,�p�y�theerre�ot (Sec 3800. b C I
Policy No rJ1��Company O� As- FOR APPLICANT TO FILL IN BUILDING e"'.30-0 QOO'D� ADDRESS
F_
Certified copy is herebl turntshed BUILDING C I If LOCALITY
ADDRESS V
1 Certified copy is'tied%pith the Lount� building inspection LOCALITY NEAREST
de tnt Temple le City CROSS ST
arme \/�{
Date � I I,�IeiG Appll',_an .1 �11 NEAREST DISTRICT NO GROUP TYP ESSED BY
I\)I —� /O �j ONS
CERTIFICATE OF L\E,IPTION FROM ',ORI:ERS CROSS ST C
LEGAL /J a
COMPENS,TIONII\SLR,\t.I_ DESCRIPTION JLOT NO 7 (BLOCK I— ..—AY
-1p (CIRCLE_) STATE MAJOR SECOND LOCAL
NO OF BLDGS '
(This section need not be completed If the %%ork Involved j—RAC— NOW ON LOT UISE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars 61001 or less.) USE OF
II SIZE OF LOT I EXISTING SLOG { '
I certtfv that In the perfnnnan.x of -lie kort or %titch -his
permit Is Issued I ,hall not 211apl0v tm -lerso,n ndm manner OWNER p 0077M fCfU�jPrZ('/ r<it'S� C. j
so as to become subject :o the t1 orkers Campensauon t.a t s _
MAIL OCCUPANC" GROUP
ADORESS/a/S�4 �I Ve =
Date Applicant _
NOTICE TO ,PPL(( INT If. .0 er mdktnc '''n u:crr iLatc nt $j CIT W( NO OCCUP4N— LOAD
L\emptnon you ,hould becopte ,umect :0 [ht 1111 kers --
L'ompensation pro,.Isions of :he Labor goat kou mUS [orTh_ 4P°LICA-ICN R = CIT {4^nCItIJ^,P -"
1 «itlt comps} \Bili such orovts,ons o• nis permit ilial be -RAILER JSE �� GEOLOGY 'NSPEC—OfJ No Spec I\���1��I
deemed re'okea
LICENSED�ONTR,CTORS DECLAR-\T10N
OCCUPANCY iNSPEcT1oN� Panic Dev cgs
11 hereby .uflrnt :hat I am !tcenselld under provtslons of Chapter
I 9 icolnmenLing with Section 70001 of Dnlsion 3 .)t :he Bn$1- SAFETY PERMIT J LIST ITEMS BE LO:'!� NO OF EXITS
ness and P-ntessions Codc and m}- license s in ud tors- ana
etfeL: (o�J PARKINGj
SPACES REO'D I PROVIDED
'n LJ ll��
= License \ulnher L,c Clays
LIMITED TIME USE
'n Contractor Date TATE OA-
N
Z ❑ �7tA
lam exempt Isom the icensmg reouuemena as l dm d
m i licensed architect or a registerea pmressional engineer SIZE OF No of I4PCR'S
z acting .n nt prctetisiondl _,,ira.:it' S,._io,t 0? 1 Bus- EXISTING BLDG STORIE7
mess na P atesu:nsC,tdel FINAL APPROVAL
J
PRESENT USE OF BUILDING d
Ltc or Ree \o Dare
T I
HOME O„NI R-13I_ILDER DECLAR \FIO\ NO OF EXISTING BUILDINGS } _E Tfi j• Il57fk!
ON LOT AND USE
I hereby dtflrm that I am exempt from the Contractor s C
I License Law for the follotsln_e reason (Section -03t s Busy
ness and PmiessionsCode) NO PARKING
El1, as .)caner of the property. «ill do the work and the SPACES PROVIDED 7+
structure Is not Intended or offered for .ale (Section ✓ V
1 7044 13usuiess and Professions Code)
CONSTRLCTION LENDING AGLNCI PROPOSED USE OF BUILDING
I licreb% affirm that there Is a construction lending agency 1 S
for the performance of the l%ork for which this permit is
issued (Sec 3097 Civ C )
Lender s Name
PROPOSED MAX OCC
Lender's address
I certift that I have read this application and state that the PERMIT FEE 25.00
above Information is Lorrect 1 agree to comply %%lth all County ISSUANCE FEE
ordinances and State laves relating to budding construction,
and hereby authorize representatives of this County to enter TOTAL FEE
I upon the above-mentioned property for inspection purposes
jgU, l SEC REVERSE E ANATORY LANGU 1GE
� �,hc� S�L�c nss 3I�3I49
Signatuk of Permittee Date