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Home My Public Portal About6322 ROSEMEAD BLVD_Miscellaneous__ WORKERS' C•OMPENSAIION DECLARATION >bM4-14Fwlzsu MISCELLANEOUS APPLICATION I' hereby affirm that I have a cerlificate of consent self COON'LY OF' LOS ANGELES BUILDING AND SAFETY DIVISION !J insure,or a certificate of Workers' C'ompensmion Insur:mcc. or a certified copy thereof (Sec. 3800. Lab.C.) Policy No.-----, Company FOR APPLICANT TO FILL IN BUILDING BUILd 5 ADDRESS ' ❑ Certified copy Is hereby furnished. LOCALITY } ❑ Certified copy Is filed with the county building inspCCIIUIt CIT ZI NEAREST department. I CROSS ST. Date Applicant SIZE OF LO N01.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CONST. CERTII IC•AH: Of- EXEMPTION I'R(>M WORKER`' TRACT BLOCK LOT NO. COMPENSAITON INSURANCE MAF HIGHWAY NO. ICIiiCLEI STATE MAJOR SECOND LOCAL (This section need no[ he completed if file work in%ohed ASSESSOR MAP BOOK PAGE PARCELr•'- USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (lt+100) ul less.) certifylll that In IIIc performance of thwl, e rk h,r N'Iliril Ilti� O NIE a TEL NO. permit is issued. I shall not employ ut ersnn in an 111el Y �(,{ r /'•� �'/�' I t I so as to become subject to the Workers' Contpen,atiun Laws. OCCUPANCY GROUP rF' i- ye, d Date _._ Applicant CITY 'IP NOTICE TO APPLICANT: It', after making this Certificate C"z ' / g OCCUPANT LOAD of Exemption, you Should become subject to the Warkers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code.you must fonlnvith comply with such provisions or this permit Shall be deeined TRAILER USE❑ GEOLOGY INSPECTION❑ revoked. � No Spec.Knowl. E]` I OCCUPANCY INSPECTIONIpI Panic Devices ❑ LICENSED CONTRACTORS DLC'l_ARMION i I I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ ILIST ITEMS BELOW, 9(commencing with Section 7000)of Division 3 of the Besiness NO.OF EXITSEl and Professions Code,and my license is in full force and effect. PARKING REQ'D PROVIDED License Number L-ic. ('lass SPACES I I P ---. — �Q--��--_- ._ ------------ -' Contractor e LIMITED TIME USE _ I U:Il DATE DATE ❑ 1 am exempt from the licensing requirements as I am a FROM: TO: ' licensed architect or a registered professional engineer 1N acting in my prolcssional capacity (Section 7051. Ihlsincss SIZE OF O.OF INSPECTOR'S EXIS TING BLDG. STORIES SIGNATURE and Professions ('ode). — _--- LIC. or Reg. No. Date PRESENT USE OF BUILDING FINAL APPROVAL Z 3'C71 e HOME OWNER-BUILDER DECLARATIONNU .OF EXISTING BUILD\ 5 ON LOT AND USE I hereby affirm that I :nn exempt front the Contractor's License Law for the following reason (Section 7031.5. Business and Professions C ode): NO.PARKING El Las owner of lite properly. will do the \\�,rk ;uul Illy SPACES PROVIDED — -- ---- ---__---- structure IS not intended lir �IIICICLI lot sale(Section /(44. PROPOSED USE OF BUILDING I Business and Professions Code). I CONSTRUCTION LENDING AGI-'N()' I hereby alfirnt that there is a cunstructiun lending atenc} fur the performance of the work for which this permit is Issued (Sec. 3097, Civ. C'.). PROPOSED MAX.OC Lender's Name _—. ____ -- ..- _. .� APP C Tl Rl,, Lender's Address . .-.__-- A D certify that I ha this application and state that the information i come t. I agree to comply with all County PERMIT FEE ord;abok-ment nd St t laws rating to building construction,and herriz r send fives of Ih,, County o ent r upon ISSUANCE FEE the on d pe ty fur inspectionpu oscs. TOTAL FEE vo /� SEE REVERSE FOR EXPLANATORY LANGUAGE Ill na a of Per I IL I ae r !. 1 WORKERS'COMPENSATION DECLARATION 4 CE 875 (11-84) MISCELLANEOUS APPLICATION - CE 87 I hereby affirm that I have a certificate of consent to self insure, ora certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES 13U1LDING AND SAFETY DIVISION a certified copy thereof(Sec. 3800,Lab.C.). L�„=1BUILDING Policy No. Company FOR APPLICANT TO FILL IN ADDRESS =� Certified copy is hereby furnished. BUILDING _ x ADDRESS LOCALITY 1 0 Certified copy is filed with the county building inspection LOCALITYTNEAREST department. _ emple City CROSS ST, Date Applicant NEAREST DISTRI NO GROJJ��P TYPE CESSED BY CROSS ST. �� /� CONST 1 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY 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 ($100) or less.) USE OF 1 SIZE OF LOTEXISTING BLDG. ` !. I 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 A MAIL X ADDRESS I • �) Date Applicant i TEL' OCCUPANT LOAD i NOTICE TO APPLICANT: If, after making this Certificate of CITY - No. 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 INSPECTIONXX 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 REO'D C� PROVIDED M License Number Lic. Class J LIMITED TIME USE Contractor Date DATE DATE 1 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 SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE V� �� •.(/) 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section vt 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 Lmap issued(Sec. 3097,Civ.C.). i •. Lender's Nameyl PROPOSED MAX. OCC. Lender's Address I -�f PERMIT FEE 25.00 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 I I t ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25.00 w) I upon the ab e-mentioned p perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r t. Si lure o enni ee Date WGr2KERS'COMPENSATIONDECLARATION CE 87454 (1184) MISCELLANEOUS APPLICATION I-'hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, , o 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 Z ADDRESS Certified copy is hereby furnished. BUILDING ADDRESS192 LOCALITY 0 Certified copy is filed with the county building inspection LOCALITY — NEAREST department. j/ CROSS ST. Date Applicant NEAREST DISTRICT NO. G O TYPE / CESSED BY CROSS ST. L.QN CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 1(/' COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCKIGHWAY NO. F BLD GS. No 'Z6 (CIRCLE) STATE MAJOR SECOND LO (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' E S 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 manner OWNER UL �' sD so as to become subject to the Workers' Compensation Laws. MAIL !�/ OCCUPANCY GROUP o ADDRESS /. , U Date Applicant w 114)NOTICE TO APPLICANT: If, after making this Certificate of CITY N ,7�, •A OCCUPANT LOAD N 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. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code, and my license is in full force and effect. PARKING REQ'D PROVIDED SPACES 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 SIG TE iness and Professions Code). FINAL APPROVAL fJ Lic.or Reg.No. Date PRESENT USE OF BUILDING i Tri O HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE f J, I hereby affirm that I am exempt from the Contractor's ' 1 License Law for the following reason (Section 7031.5, Busi- 344--1 FEFE 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). -`'aJ =' CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDINGI€; I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address I certi y that I have read this application and state that the PERMIT FEE above nformation is corre t.I agree to c ply with all County ISSUANCE FEE ordina ces S to la s ting to ilding construction, and h r aut ize re tative this Cou ty to enter TOTAL FEE VV n e- perty nspectio pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE ature o er itte(j� rat WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 11affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insureure,, o 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 /' �� iN/ ADDRESS 6 Certified copy is hereby furnished. BUILDING �l Z LOCALITY ADDRESS [... 0 Certified copy is filed with the county building inspection f LOCALIT /� ( i NEAREST 00, department. \1 \\� cRoss ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE RO ESSED BY CROSS ST. In � ;l� CONST. (J 9 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP 2 "I�� HIGHWAY STATE MAJOR SECOND LOCAL N0.�52_ (CIRCLE)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.) us E OF C� d 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 ]✓ so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADDRESS r Date Applicant „1 NOTICE TO APPLICANT: If, after making this Certificate of I, NO. (L� `773 OCCUPANT LOAD 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 ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI ❑ (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 i` \ _ ,G effect. �'e Q.S PARKING SPACES REQ'D PROVIDED License Number Lic. 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 INSPE CTO acting in my professional capacity (Section 7051, Bus- XISTIENG BLDG. STORIES sIGNAT RE iness and Professions Code). FINAL APPROVAL RESNT USE OF BUILDING QW Lic.or Reg.No. Date ' v HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUI GSo EE� 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- ✓1^�� OC100-00 !j 1/ 4/90 ness and Professions Code): NO. PARKING \✓ I F] I, as owner of the property, will do the work and the SPACES PROVIDED tib �`ii" 9:75 uj�'. f •__I 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 x n 1 C) Y.) for the performance of the work for which this permit is !�� issued(Sec. 3097,Civ.Q. ` Lender's Name I I O PROPOSED MAX. OCC, ll 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, andou by authorize re resentatives of this County to enter TOTAL FEE s the bove-mentio ed roperty for inspection purposes. Signature SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76EM84541�-80) M ISC E LLA N EO'US 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 XI W Le Certified copy is hereby furnished. BUILDING LOCALITY t El [p Certified copy is filed with the county building inspection ADDRESS NEAREST department. cwLITY / ceoss ST. Date Applicant BAREST h DISTRICT NO. R CrUP PE PRO SSED BY CROSS ST. I.ell CONST---- CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALLor COMPENSATION INSURANCE DESCRIPTIONLOT NO. BLOCK MAP IGHWA. NO. - (CIRCLE) STATE MAJOR SECOND LOCAL a41 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 ($100) or less.) U USE OF SIZE OF LOT EXISTING BLDG. / �.�� 0 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 WNER & / i I- so as to become subject to the Workers' Compensation Laws. AIL t��f OCCUPANCY GROUP.. r� U Date Applicant AODREss �. 9- � TEL NOTICE TO APPLICANT: If, after making this Certificate of CITY No, � [ OCCUPANT LOAD Exemption, you should become subject to the Workers' PLICATION 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. ❑ No Spec. Knowl. ❑❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby,affirm that I 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 e"1feCt. SPACES REQ'D PROVIDED License Number Lic.Class LIMITED TIME USE Czntractor Date DATE DATE ❑ FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus-' EXISTING BLDG. STORIES SIGNATURE iness and Professions Code), NAL APPROVAL FI > RESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTIN BUILDINGS ON LOT AND'U I hereby affirm that, I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- 50 3 ness and Professions Code): NO, CARPING SPACES PROVIDED I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section z Z 7044,Business and Professions Code). R.POSED USE OF BUILDING - 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. 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 above-mentioned property forIns ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o Permittee Dat WORKERS'COMPENSATION DECLARATION CE 8754(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 BUILDING *j 22 ❑ ADDRESS J Certified copy is hereby furnished. BUILDING LOCALITY DDRESS 6322 I:,Rosemead r_1 Certified copy is filed with the county building inspection NEAREST department. LocaurY Tenple City, Ca. 91780 CRO55 ST. Date Applicant NEAREST DISTRICT'N O/. O TYP PROLE SED BY CROSS ST. ^{y CO ST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP ��•l�03 HIGHWAY � NO. �(/ `^� (c IRcLE) STATE MAJOR SECOND LOCAL d NO. O OF SLOGS. (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 2 IZE OF LOT EXISTING BLDG. I 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 OWNER�j�= i11l — g Design V so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP , W DDRESS 337 Sacr ento Place CL Date Applicant rn NOTICE TO APPLICANT: If, after making this Certificate of CITY Ontario Ca. NO. (714)983-826:1 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 EJ GEOLOGY INSPECTION deemed revoked. ❑ No Spec. Knowl. ❑❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E] 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 effect. PARKINGSPACES REO'D D PROVIDED D License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE F1 - FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). RESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date e•• (J / taming salon 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- D 4 0 0.7'A ness and Professions Code): NO.PARKING z SPACES PROVIDED I, as owner of the property, will do the work and.the # o'D ° D 40. structure is not intended or offered for sale (Section . ' ' N 7044, Business and Professions Code). o o D•D O e D 2 PROPOSED USE OF•BUILDING , CONSTRUCTION LENDING AGENCY 0 24 0 9—81 I hereby affirm that there is a construction lending agency tanning and manicurist salon 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 ree to comply with all County ISSUANCE FEE ordina ces nd S e law rel ing to building construction, TOTAL FEE and hereby aut Ize re se atives of this County to enter on the o mer t, for inspecti_ p r uses. SEE REVERSE FOR EXPLANATORY LANGUAGE x Si ature of Permittee Dat 1I 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' �a ADDRESS ❑ Certified copy is hereby furnished. of BUILDING 6 L� LOCALITY ADDRESS - ❑ Certified copy is filed with the county building inspection NEAREST department. iu1_7ocaTv^� �� q � 8V CROSS ST. Date Applicant NEAREST ■ V DISTRICT NO. GROUP TYP PROCESSED BY ROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L'4` -/—� DESCRIPTIONLOT NO. BLOCK COMPENSATION INSURANCE NO. F BLDGS. NOP 66T (cGRc E) STATE MAJOR sEcorID LOCAL (This SOCtIOn 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. 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 �0 BfZIS so as to become subject to the Workers' Compensation Laws. MAIL //�) /�v OCCUPANCY GROUP / W G ADDRESS �W I�^�� CL Date Applicant TEL W NOTICE TO APPLICANT: If, after making this Certificate of Tv c ^l.�- �. NO.-7I4-•q g us OCCUPANT LOAD 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[JGEOLOGY INSPECTION NO Spec. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT [I (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 REQ'D E= PROVIDED D License Number - Lic. Class LIMITED TIME USE Contractor Date DATE DATE ❑ FROM: To: I am exempt from the licensing requirements as I am licensed architect or a registered professional engineer SIZE OF NO. OF a INSPECTOR'S acting in my professional capacity (Section 7051, Bus-' EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). r FINAL APPROVAL �R ESE NT USE OF BUILDING I7,S ^�h Lic.or Reg.No. Date I HOME OWNER-BUILDER DECLARATION No. of AND ING 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 SPACES PROVIDED ❑ I, as owner of the property, will do the work and the z,2 7 1.2 A structure is not intended or offered for sale (Section 7044, Business and Professions Code). d" y2.6z # o 0 0 0 8 8' 'PROPOSED USE OF BUILDING '1 J Q,i.`�L CONSTRUCTION LENDING AGENCY o;0 0 0 0 0 o z I hereby affirm that there is a construction lending agency !�►�—Ties t a. ° ' for the performance of the work for which this permit is 0 1,22L-82 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 kbove information is correct.I agree to comply with all County ISSUANCE FEEdinances and State lawsrelating to building construction, TorAL FEE d hereby authoriWrepsentatives'of this County to enter n the above-me plertyfor inspection purposes. SEE REVERSE ORE PLANATORY LANGUAGE Sk nature of rmittee Date I WORKERS' COMPENSATION DECLARA140N 20-0063DPW72/90 MISCELLANEOUS APPLICATION I. hereby affirm that I have.a certificate of consent to self COUNTY OF LOSANGELES BUILDING. AND SAFETY DIVISION insure,or a certificate of.Wdrkers'Compensation Insurance,or V ' I a certified copy thereof (sec. 3800, Lab. C.), Policy:No. Company FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRESS ADDRESS i ❑ Certified copy,is hereby.furnished. it 3.502 POz e'd 5fad LOCALITY ) ❑ Certified copyis filed with the county building inspection CITY ZI department NEAREST l� �O CROSS ST. ' Date Applicant SIZE O LOT NO.OF BLOGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY G CERTIFICATE OF EXEMPTION FROM WORKERS' o G coNsr. /� TR CT BLOCK LOT NO. ' 1 ,. .. .COMPENSATION INSURANCE - IL NOP CIRCLE) STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involvedASSE SSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) . TyQ�2lFtrt�y et - TEL NO. I.certify that in the performance.of the work for which this s �/� (NO. �(3 permit is issued.I shall not employ any person in any manner ' 14 a I so as to become subject to the Workers' Compensation Laws. A DRESS may. _ OCCUPANCY GROUP Z Date Applicant CITY IP — NOTICE TO APPLICANT: If' after making this Certificate rq n_ 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) 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 dt Bustness PARKING• REO'D D PROVIDED D License Number Lic. ClassSPACES ' Avw4 A-is Tov Contractor Date LIMITED TIME USE ❑ 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 SIZEOIF BLDG. NO.OF STOES INS ECNATURER'S EXISand Professions Code). Lic. or Reg. No. Date PRESENT USE OF BUILDING FINAL APPROVAL 7 2 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.PARKING SPACES PROVIDED ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale(Section 7044,X PROPOSED USE OF BUILDING Business and Professions Code). CONSTRUCTION LENDING AGENCY ku� ✓c LAY 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 APPMLICA T TPR I TEL NO. t�CI �l� Lender's Address ADDRESS I certify that I have read this application and state that the 6J�7 above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-ment_ione ropert for inspection purposes. 1'•i._ i TOTAL FEE X SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date