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HomeMy Public PortalAbout6320 ROSEMEAD BLVD_Miscellaneous__ 76M444-CE40764-67 MISCELLANEOUS APPLICATION COUNTY OF LOS ANGELES BA D ul Lol DEPARTMENT OF COUNTY ENGINEER DRE S S BUILDING AND SAFETY DIVISION JOHN A. LAMBIE, COUNTY ENGINEER LOCALITY COLEMAN W. JENKINS, SUP'T. OF BUILDING NEAREST ��SL,�//�n�/,q CROSS ST. FOR APPLICANT TO FILL IN DISTRICT NO. GROUP TYPE PROCESSED BY (U C ST t L BUILDING G HIGHWAY ADDRES NO. (CIRCLE) STATE MAJOR SECOND LOCAL LOCALITY (� �1 ( �� USE ZONE SPECIAL CONDITIONS NEAREST ST. � `� CROSS S . LEGAL REQUIRED YARD HWY STREET NAME EXIST. DESCRIPTION LOT NO. BLOCK SETBACK WIDTH FRONT NO. OF BLDGS. P.L. TRACT NOW ON LOT SIDE USE OF P.L. SIZE OF LOT EXISTING BLDG. I P OWNER ` I L MAIL —6w_,&__ ADDRESS CITY NO. C' O APPLICATION FOR Efv OCCUPANCY yn.G INSPECTION SAFETY PERMIT ~ N.g /= L L v- w TRAILER USE CL Z USE OF STRUCTURES OR DEVICES L- LIMITED TIME USE DATE DATE FROM: ^.Z TO: INSPECTOR'S APPROVALS DATE SIGNATURE OCCUPANCY APPROVAL I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS GROUP OCC. LOAD APPLICATION AND STATE THAT THE ABOVE IS COR- RECT AND AGREE TO COMPLY WITH COU TY TRAILER USE ORDINANCES AND SXATE LAWS RE ING CH WORK AS INDIC AT ON. SIGNATURE OF -�+4-BETY PERMIT PERMITTEE TEMPORARY STRUCTURE APPROVED ADDRESS �L TEMPORARY STRUCTURE REMOVED FEE [ FINAL APPROVAL J I Z APPLICATION VALIDATION JOHN F. LEWIS, PRINCIPAL STRUCTURAL ENGINEE (NOT A PERMIT) CK. M.0. CASH PERMIT VALIDATION CK. M.0. CASH LAAO 4 7 7 8.:01 �'r�1'l�� � a 15.00— ^WORKERS'CODIPENSATI ONDECLARATION CE 875(11-84) 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 certified copy thereof(Sec. 3800,Lab.C.).• Policy No. Company FOR APPLICANT TO FILL IN BUILDING >p7LLa�� ADDRESS Certified copy is hereby furnished. BUILDING ADDRESS 6320 N ROSEMEAD BLVD LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST z 47 department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE CESSED BY CROSS ST. �- rn CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �,df a COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF HLDGS. (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 SIZE OF LOT EXISTING BLDG.OF d I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP MAIL 0 ADDRESS I— Date Applicant Lam' NOTICE TO APPLICANT: If, after making this Certificate of CIT _ OCCUPANT LOAD y Exemption, you should become subject to the Workers' z APP LICA ION FOR Compensation provisions of the Labor Code, you must forth- �,3,� EXIT HARDWARE: _ with comply with such provisions oI 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 Exlrs ness and Professions Code, and my license is in full force and Effect. PARKINGREq PROVIDED D SPACES License Number Lie. Class LIMITED TIME USE /A1, Contractor Date �� •v 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- EXISTING BLDG. STORIES SIG ATURE iness and Professions Code). FINAL APPROVAL //�� L PRESENT USE OF BUILDING Lie.or Reg.No. Date C (( HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I 1 hereby affirm that I am exempt from the Contractor's yl�e. 0000-0001 01 i'16/9 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING ,/� 3697 f PM 1:41 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 s 2 1 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 G I certify that I have read this application and state that the above information is correct. agree to comply with all County ISSUANCE FEE ordinances and State laws lating to building construction, and hereby author' e pres ntatives of this County to enter TOTAL, FEE upon th above-m ti h d oper- inspection purposes. G,,/ SEE REVERSE FOR EXPLANATORY LANGUAGE na re of P i e Date WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent self 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.) Policy No. Company FOR APPLICANT TO FILL IN ABUILDING DDRESS ❑ Certified copy is hereby furnished. W BUILDING 6 )�. ADDRESS LO NO. LOCALITY 7� ❑ Certified copy is filed with the county building inspection V I NEAREST department. LOCALITY 'T ` 7- CROSS ST. Date Applicant EAREST < G _l DISTRICT NO. ROUP T E PROCESSED BY CROSS ST. LON /V © DNST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. 2BLOCK MAP' HIGHWAY NO. CIRCLE STATE MAJOR SECOND LOCAL CL ' NO. OF BLDGS. (This section need not be completed if the work Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0 by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. �•� cc 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 LdWNERavp U . so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP LU ADDRESS 10 Date Applicant Z NOTICE TO APPLICANT: If, after makingthis Certificate of CITY TEL. 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 deemed revoked. ❑ Cl No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ a j,hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS (commencing with Section 7000) of Division 3 of the Busi- eiess and Professions Code, and my license is in full force and PARKING effect. REq'D D PROVIDED SPACES License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF FROM: To: INSPECTOR'S acting m my professional capacity (Section 7051, BUS- EXISTING BLDG. Z Sa'! , FT STORIES SIGNATURE iness and Professions Code). /1� FINAL APPROVAL r 7 4 / RESENT USE OF BUILDING YAVrn/T /- Lic.or Reg.No. Date //77 HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that, I am exempt from the Contractor's z 3 5 S 4 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): No.PARKING SPACES PROVIDED # 0 0 0 0 88 ❑ 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section D D 0 0 0 o a z 7044, Business and Professions Code). 0W6POSED USEOF BUILDING 7'476C ,-q(--C7J V G/��[ O,o•i]O� O CJ 4 CONSTRUCTION LENDING AGENCY n�7.�/� 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, TOTAL FEE and hereby authorize representatives of this County to enter upon the abo p -mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ture of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION CE 875 I hiaffirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insuree,, or-a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No., _ _CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy.is hereby furnished. uILDING C) LOCALITY ADDRESS U ,�"`�J�,"Q_C7� ��`J Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE p CESSED BY CROSS ST. CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP HIGHWAY NO. F BLD 65. NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. >0:I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER C J �y� j� , CD y so as to become subject to the Workers' Compensation Laws. / OCCUPANCY GROUP _� MAIL (` 1-� �/ vl V-L) �U U ADDRESS V Date Applicant 8 11 � TEL I �� OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY No. d cin 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. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION EJ El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 9 (commencing with Section 7000) of Division 3 of the Busi [J (LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code,and my license is in full force and effect. , PARKING SPACES REQ'D D PROVIDED O .. License Number Lic. Class T W✓� C 1 e�,vtr�,. LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. FROM: TO: OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL /l_-i`/� PRESENT USE OF BUILDING ( ``�� Lic.or Reg.No. Date .� Lt� HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS NO FEE ! 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 FII—i"0111 ness and Professions Code): No. PARKING `�fI _ 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 CA112AA,Q11-5 I Hereby affirm that there is a construction lending agency for the performance of the work for which .this permit is issued(Sec. 3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE l't� 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 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL, FEE p�5 upon thea e-mentioned roperty for inspection purposes. X r Z2_nil SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ` WORKERS' COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION ter"? CE ale L;ereby 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 iSec. 3800. Lab.C.). `y Policy No. —Conipany FOR APPLICANT TO LL IN BUILDING ADDRESS Certified copy is copyAD ADDRESS hereby furnished. BUILDING /� LOCALITY I (f (+ �7 // i 1 Certified copy is filed Lvltil Ilte 011 nt building inspectioninspection01 LOCALITY Temle City �`IJ NEAREST department. p J CCZ�JJJJ CROSS ST. Date applicant NEAREST j MISTR T NO GRO JP TYPE PROCESSED BY CROSS ST. � �( CONST. ` CERTIFICATE OF EXEMPTION FROM'.1ORKERS I LEGAL L 'C/J COMPENSATION INSL RaNC.1= 0 E S CR IPT!ON LOT NO. (BLOCK A GRW AY(CIRC—) STATE MAJOR SECOND LOCAL ! NO. OF BLOGS. (This section need not be completed if the .vork involved i TRACT NOVI ON LOT USE ?ONE SPECIAL CONDITIONS by the permit is for one hundred dollars 6100) or less.) usE OF 1 SIZE OF LOT I EXIS ING BLDG. I certify that in the nertonr.ance of 'he sorb: for --aliich thisFLUVCLty – permit is issued. I shall not employ am' -3e-.son in am manner CwNER so as to become subject :o the 'Aorkers ompensatien laws- OCCUPANC`' GROUP — MAIL ADDRESS i Date .applicant . 'E_. NOTICE TO APPLICANT: 11, after makins :.us Certit.icate 0[ X]clrr No. OCCUPANT LO.JAC Exemption, ou ;iiould become �ubiect ro the Wnrkers APDL!CA7!CN `CF. = IT HARC':i:�F,C Compensation pm�visions of the Labor .:ode. %-ou !Host forth- _ i with coitiniv with :uch nrovi6)ns I,- his neiniii shall be -RAILEa US. ] ��EOLJGY :NSP=CTICN _ No Spec. <1notvlu deemed rcLoked. . – LICENSEDCONTRACTORSDECLARATIO` OCCUPANCY INSPECTIONgg Panic De/lees I hereby ifirm :hat I am licensed under orm-isions of Chapter — SAFETY PERMIT (LIST ITa;��P t 9 (commencing with Section 7000) of Division 3 of the 3us1- `– No. OF EXITS ness and Professions COLIC. and my license a in alit three and /� /��' effect. /v4CJ 4 RKING j SP4CES REO�O I 1 PRCVID ED License NUITIber Lc. Class LIMITED TIME USE N Cuntractnr Date DA— TO: tam exempt from the licensing requirements as I am .I licensed architect or registered professional engineer slzE of I No. G a reNSPE CTO S i - SNATURE z acting n :nv profes � t sional _:r.a tt,: S . io:i _0. 1- u[- . l3EXISTING BLDG. TOR!-5 I ° iness and Proiessicns e). FINAL APPROVAL Cod J PRESENT USE OF BUILDING Lic. or Reg. No. _.I ' hd HOME O«N1 R-B1:ILDER DECLARATION NO. OF EXISTING BUILDINGS � ' fit' x j ON LOT AND USE I hereby affirm that l am exempt from the Contractors 1, 1 License Law for the following reason (Section 7031.5. Busi- ness and P-m essions Code l: NO. PARKING 1, as owner of the property. will do ;hc work and the SPACES PROVIDED structure is not intended or offered for ;ale (Section 1 7044, liusiness and Professions Codel, p CONSTRUCTION LENDING AGLN( i X PROPOSED USE OF BUILDING I liereby affirm that there is a construction lending agency S S } for the performance of the Isork for which this permit is issued(Sec. 3097,Civ.C.I. Lender's Name – PROPOSED MAX. OCC. Lender's address I I certify that l have read this application and state that the PERMIT FEE 25.00 above information is correct. I agree to comply with all Countv ISSUANCE FEE ordinances and State IaLvs relating to building construction. and hereby authorize representatives of this County to enter TOTAL FEE 25��� t upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I � I Signature of Permittee Date WORKERS' CON1PENSAHON DECLARATION I0MIta zo-not>soPwlz�no MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent III sell* COUN'IY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,or a certificate of Workers' Compen,ation Insurmcc, Or fa certified copy thereof (Sec. 3800. Lab. C.) 3 Policy No. _ _ Cum pally FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRESS ADDRESS ❑ Certified copy is Hereby furnished. �32d- LOCALITY ❑ Certified copy filed with the county building inspection CITY ZIP _ NEAREST J department. -F m I CROSS ST. Date _ Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CONST. t' C'ERTIPIC'All: OF EXEMP-11ON FROM WORKLRS (' . ) COMPENSATION INSURANCTRACT BLOCK LOT NO. E NAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work itv ol%e(lASSESSOR MAP BOOK PAGE PARCEL t`= by (be permit is for 011e' hundred dollars (ti,1)01 or lc%s.) USE ZONE SPECIAL CONDITIONS (.., OWNER (� TEL NO. 1 certify that in the performance n1' the work for whit h Illi, l� I T L permit is issued, I shall not cm to eison UI an wanner Vp p' p y any 1 }' so as to become subject to the Workers' Compen,ation Laws. ADDRESS _ ^ OCCUPANCY GROUP tr, /'t d., Dale Applicant CITY ZIP NOTICE TO APPLICANT: If, after making this (enificate Cre 9� gto OCCUPANT LOAD of Exemption, you should become subject to the W;'irkers' APPLICATION FOR Compensation provisions of the Labor Code,you must farhwith I EXIT HARDWARE: I comply with such provisions or this permit Shall be dCemCd TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ _ revoked. y� - OCCUPANCY INSPECTIONIpI Panic Devices ❑ LICENSED CONTRACTORS DEC'l_ARNHON 6 1 hereby affirm that I inn licensed Under provisions of C haptef SAFETY PERMIT❑ (LIST ITEMS BELOW { 9(commencing with Section 7000)of Division 3 of the Bt'siness NO.OF EXITSEl \{ and Professions Code.and my license is in full force and effect. � � �� J5 PARKING• SPACES REQ'DDPROVIDEDLicense Number Lie Class I D ' 1 I Contractor Date LIMITED TIME USE DATE DATE _ I ❑ I am exempt from the licensing requirements a'; I :Int a FROM: TO: j licensed architect or a registered professional engineer ! F. SIZE OF NO.OF INSPECTOR'S acting in my professional capacity (tirclion 7tlil. ISusiness 45 UGO .•tet EXIS rINC;BLDG. SrORIC.S SIGNATURE and Professions Code). FINAL APPROVAL. LIC. or Reg. No. Date } cy - PRESENT USE OF BUILDING ,n���-meq • i t I HOME OWNER-BUILDER DIA LARAIION IJ13.orExI511NCBu1LDINGS - - ON LOT AND USE I hereby affirm that I am exempt from the C'ontractor's License - - Law for the following reason (Section 7031.5. Business and Professions Code): NO.PARKING SPACES PROVIDED ❑ L as owner of the properl�',ll\01 do the \cllrk ;Ind the — --- - --- --- structure IS not intended Ur oCI'ed IUI S:IIC (ticCl Zoll 70 4-41 PROPOSED USE OF BUILDING Business and Professions Code). ttl F- �f�at.eJa.� CONSTRUCTION LENDING AGENCY hereby affirm that there is it Construction lending agent} for the performance of the work for which this permit is issued (Sec. 3097,CIV. C.). PROPOSED MAX.OCC. Lender's Name --___-._-- - AP LICq NT!PRINT) TEL NO. M Lender's Address -...... .. .- _. _ ADDRESS �� ' I I certify that I have read this application and state that tile __e �� C• I ! above information is correct. I agree to comply with all County PERMIT FEE `1 Y1 j ordinances and State laws relating to building construction,and Q hereby authorize represLiltves f this County to enter upon ISSUANCE FEE �t a ve- inspection purpo,Cs. TOTAL FEE �( I � I � O SEE REVERSE FOR EXPLANATORY LANGUAGE o In ignature of Permittee Date I i � "ORI;ERS' °M1IPENSAI,°" °':(CARAT`°" CE 875 (11-84) M ISCELLANEOUE, APPLICATION CE 875 I hereby affirm 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.). 42 Policy No.-- Company— FOR APPLICANT TO FILL IN BUILDING �� ADDRESS FICertified co is hereby furnished. BUILDING �.ry�^�/}�J� I�QQQ,Q,����A A,` / copy y x ADDRESS. 320 f k ✓Q6 M -VV-b / LOCALITY v ElCertified copy is filed with the county building inspection - LOCALITY � 1- i y NEAREST department. Xy. & P CROSS ST. Dale_ -__Applicant _ NEAREST r/ �* ` DISTRICT NO. G UP TYPE P CESSED BY CROSS ST. 1/'� �"� , U CONST. Grp` Cl:RTII ICATf;OP EXEMPTION FROM WORKERS' LEGAL a C.OM1'II�ENSA TION INSURANCE DESCRIPTION LOT NO. BLOCK „IAP HIGHWAY NO. (C,RCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (Tills 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 EXSTING BLDG. r I I certify that in the performance of the work for which this EXTI n permit is issued, I shall not employ any person in anymanne3cX OWNER of buildingl-v J INI���. so as to become suhjecl to the Workers' Compensation laws. MAIL (/, A {//� OCCUPANCY GROUP ADDRESS Date _ Applicant __ w TE NOTICI: TO APPLICANT: If, after making this Certificate of CITY (()� NoL OCCUPANT LOAD C/3 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 lir this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices a 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 it effect. Name of business PARKING REQ'D pROVID ED s t License Number. Lic. Class O vi lr������ SPACES LIMITED Contractor---.- .__ _-___- Date DATE IDATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.of ;(�-€�lINSPegiO:gs:; 7 EXISTING BLDG. STORIES SIGNArTUR.Er acting in my professional capacity (Section 7051, Bus- ar�C iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg. No. _ Date - 3 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE V �1 1 hereby affirm that I am exempt from the Contractor's J 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 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 [ 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 atithotrzp representatives of this County to enter TOTAL FEE 25 - 00 ' upon the above-n to 141 d proG'rt};for'nspection purpos • ` jSEE REVERSE FOR EXPLANATORY LANGUAGE XX----- ll� -- XX -3 Cirnatlur rrn,itler - I .Ite WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm•that I have certificate of consent self 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.) Policy No. CompanyFOR APPLICANT TO FILL IN ABUILDIN DDRESS ' r Certified copy is hereby furnished. BUILDING '" O ADDRESS LOCALITY .� Certified copy is filed with the county building inspectiont .•� NEAREST department. LOCALITY �/�{.� ,p / CROSS ST. Date Applicant EAREST DISTRICT NO. G OUP PRO SSED BY CROSS ST. ) NSTt y CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I ci COMPENSATION INSURANCE DESCRIPTION L NO. BLOCK MAP HIGHWAY rvo. (CIRCLE) STATE MAJOR SECOND LOCAL CL NO. OF BLD S. 0 by t section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS - 0 by the permit is for one hundred dollars ($100) or less.) OSE OF I certify that in the performance of the work for which this SIZE OF I,,0T EXISTING DG. -:24 0 permit is issued, I shall not employ any person in any manner i WNER l H so as to become subject to the Workers' Compensation Laws. AIL ` OCCUPANCY GROUP W Date Applicant ADDREss �- NOTICE TO APPLICANT: If, after making this Certificate Of CIT 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 ❑ Spec. Knowl.SP ❑❑ deemed revoked. No❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I,bereby 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. (� effect. REO'D I PROVIDED SPACES -I - License Number Lie.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- EXIS .ING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL ESENT USE OF BUILDING Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION PN.. o EXISTING BUILDINGS # 0 0 0 0 8 8 L AND USE .. . O O'.a 0 0 0 0.Z I hereby• affirm that- I am exempt from the Contractor's + License Law for the following reason (Section 7031.5, Busi- nessand Professions Code): NO. PARKING SPACES PROVIDED 1, as owner of the property, will do the work and the structure isnot intended or offered for sale (Section 7044, Business and Professions Code). ROPOSED USE OF BUILD,INjp 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 Dal(X PROPOSED MAX. OCC. i Lender's Address PERMIT FEE ! I certify that I have read this application and state that the I above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE ®� 2jpC an hereby authorize represent fives of this County to enter u the a ove-menti n p erty for in i n p oses. y�EE REVERSE FOR EXPLANATORY NGUAGE ignature of Permitt Date I