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Home My Public Portal About6334 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION CE 875 I hereby t a erthat 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 / 22 ADDRESS Certified copy is hereby furnished. BUILDING ADDRESS , LOCALITY 0 Certified copy is filed with the county building inspection LOCALITY / EAREST department. ( , CCROSS ST.. 91 Date Applicant NEAREST DISTRICT NO. GROUP TYPE CESSED BY CROSS ST. CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL d COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP HIGHWAY NOOF LD 65. NO. (CIRCLE) STATE MAJOR SECOND LOCAL . (This section need not be completed if the work involved TRACT NOW ONBLOT 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 Wy so as to become subject to the Workers' Compensation Laws. MAILNER nA1CUP jUCY GROUP '^) aftt_, ® c� ADDRE 1/ V Date Applicant C_J TEL. OCCUPANT LOAD NOTICE TO APPLICANT: If;after making this Certificate of CITY lip S, o N Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code,you must forth LICATION FOR a EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked. ❑ E] No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 Of the Busi SAFETY PERMIT ❑ (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 License Number Lic. Class St`.C'!/�C� LIMITED TIME USE Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF No. of FROM: TO: INSSP CTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES s. TORE iness and Professions Code). FINAL APPROVAL Q„ PRESENT USE OF BUILDING �LCC1l Lic.or Reg.No. Date e�s HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ^ C 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 =~ # € PIN '.2= 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. 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 ws relating to building construction, and hereby autho ' r presentati es of this County to enter TOTAL FEE upon the ab nti led pr ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE a� Signatu of Permittee Date WOR$ERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION CE 875 I he.*�io 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 ADDRESS Certified copy is hereby furnished. uILDING ^'� ADDRESS LOCALITY Certified copy is filed with the county building inspection LOCALIT department. ;� ,. Ci, NEAREST G� 11�� CROSS ST. Date Applicant -NEAREST . DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. Lv` t'�•+��(��+ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 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 ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF I certify that in the performance of the work for which this SIZE of Lor EXISTING BIND G. O permit is issued, I shall not employ any person in any manner OWNER Z okkp„t..t• so as to become subject to the Workers' Compensation Laws. MAIL ` OCCUPANCY GROUP / o ` ` ,[ Date Applicant ADDRESS fo33� 14D OS� SAD \�� L~il - c� NOTICE TO APPLICANT: If, after making this Certificate of cIT w� G 1 — (�. No 0 t 35 OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PER ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING SPACES REQ'D DF PROVIDED D License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FROM• TO. licensed architect or a registered professional engineer SIZE OF NO. OF PNC EroR's acting in my professional capacity (Section 7051, Bus- STING BLDG. STORIES SI RE iness and Professions Code). n Date FINAL APPROVAL Lie.or Reg.No. PRESENT USE OF BUILDING C.:�L.t�1�1�1� C it HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS Z Y$,A / A ON LOT AND USE I hereby affirm that I am exempt from the Contractor's # o,o o • 88 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING E] 1, as owner of the property, will do the work and the sPwcEs PROVIDED 0 0 0 0 • o o structure is not intended or offered for sale (Section 0 61 ,0-8 8 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency N&, eNC 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 guEpKh the above-mentioned prop rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE A. S- �a-q S a ignature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS A P P L I C A T I O N I hereby a617-in that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION `4 insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab. C.) 7. Policy No. BUILDING Company FOR APPLICANT TO FILL IN ADDRESS J ❑ Certifiedcopy is hereby furnished. BUILDING , 'I �cr t/!1/L _ LOCALITY ADDRESS ❑ Certified copy is filed with the county building inspection a NEAREST department. LOCALITY I ^ .� CROSS ST. Date Applicant NEAREST u� DISTRICT NO. G UP TYPE RO SSED BY CROSS ST. CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL r r COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NO. GHWAv STATE MAJOR SECOND LOCAL d a./ ��](CIRCLE) (This section need not be completed if the work involved NO. OF BLDGS. 0 p TRACT NOW ON LOT USE ZONE SPECIAL.CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE TI C_.v SI OF LOT - EXISTING BLDG. 1 certify that in the performance of the work for which this , 1 permit is issued, I shall not employ any person in any manner 1, \ ~ so as to become subject to the Worker ' Compensation La 's.. v �Q s OCCUPANCY GROUP W CL Ess O A Love P v U) DatePPlicant rEL z NOTICE TO APPLICANT: If, peer making this Certificate of ITY rvo 3—+500 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 USEGEOLOGY INSPECTION deemed revoked. � C3 No Spec. Knowl. ❑ occuPArvcY INSPECTION Panic DOVIC@S ElLICENSED CONTRACTORS DECLARATION 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• effect. SPACES REQ'D PROV ID ED 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 'F NO. OF slATURE INSPECTOR'S acting in my professional capacity (Section 7051, Bus- exI ING BLDG. STORIES iness and Professions Code). ESENT USE OF BUILDING //�Au FINAL APPROVAL Lic.or Reg.No. Date �N HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that, I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING ) SPACES PFjOVID ED I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section Jr 9 7 6 A 7044, Business and Professions Code). OPOSED uSE OF BUILDING �. C/Gr�NLIL ^�n CONSTRUCTION LENDING AGENCY V # 000988 I hereby affirm that there is a construction lending agency 10 0.0 0 0 0 0 o z � for the performance of the work,for ,which this permit is N issued(Sec. 3097,Civ.C.). \� 1;] 9'!-86 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 thorize representatives of this Coun to enter upo the ve-mentione ro eve f SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ermittee 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. ✓ BUILDING LOCALITY p ADDRESS .✓ I Certified copy is filed with the county building inspection //ryry NEAREST department.. LOCALITY / / CROSS ST. Date Applicant AREST V DISTRICT �GR 'TYPE PROCE SED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �L7 COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP IGHWAY rvo. _ (CIRCLE) STATE MAJOR SECOND LOCAL IL NO. OF BLDGS. 0 (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. o I certify that in the performance of the work for which this eo permit is issued, I shall not employ any person in any manner L15WNER4zv _ U so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP IL ADDRESS L LA Q Date Applicant Z NOTICE.TO APPLICANT: If, after making this Certificate of CITY /� No� 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 ❑ ❑ No Spec. Knowl. ❑❑ deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Thereby 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- ,pess and Professions Code, and my license is in full force and PARKING. I�� effect.- SPACES REQ'D U PROVIDED License Number Lic.Class LIMITED TIME USE _ Contractor Date DATE DATE 0 Iam exempt'from the licensing requirements as I am a ' FROM: TO: licensed architect or a'registered professional engineer SIZE OF NO. OF INSPECTOR'S' acting In my professional capacity (Section 7051, Bus- EXISTING.BLDG. STORIES �i SIGNATURE iness and Professions Code). P SENT USE of BUILDING G�=QNir✓ FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE Z 2 5 6 2•A I hereby affirm that, I am exempt from the Contractor's # o D o 0 88 License Law for the following reason (Section 7031.5, Busi- nessand Professions Code): NO.PARKING SPACES PROVIDED 0 0 0 0 0 0 0 ❑ I, as owner of the property, will do the work and the I I • 1 structure is not intended or offered for sale (Section 0'7-09-84 7044, Business and Professions Code). P SED USE OF BUILDING - CONSTRUCTION LENDING AGENCY r 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. I 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 thbov mentioned p er for inspecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 1 c Signatu,e 1 er tee ate WORKERS'COMPENSATION DECLARATION 76M444 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. CompanyFOR APPLICANT TO FILL IN wDoeEss0011,11, ❑ Certified copy is hereby furnished. BUILDING oc ALITY 434 ❑ DDRESS L' U I Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. Date Applicant NEARESTDISTRICT GROUP PE PRO ESsED BY ' CROSS ST. A/ �e P CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL /� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP (CIRCLE, LE, >• NO. (CIRCLE) STATE MAJOR SECOND LOCAL � (This section need not be completed if the work involved NO. of BLDGS. USE ZONE SPECIAL CONDITIONS P TRACT NOW ON LOT 0 by the permit is for one hundred dollars ($100) or less.) USE OF L) ZE 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 wNER ' so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP LU' W DRESS Date Applicant y v TEL. NOTICE TO APPLICANT: If; after making this Certificate of CITY �. CJ:! No. =—g� OCCUPANT LOAD Exemption, you .should become subject_ to the Workers' Compensation provisions of the Labor Code,*you must forth- APPLIC 'TION FOR EXIT HARDWARE: with comply with such. provisions or this permit shall be TRAILER USE GSECTION deemed revoked. [_ GEOLOY INSPECTION Spec. Knowl. Q Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONEl Ihereby 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 SPACES er�feCt. 'REQ'D PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE TO: UI 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- XISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL RESENT USE OF�BUILDING - Lic.or Reg.No. Date CCNrap EXvex HOME OWNER-BUILDER DECLARATION NO. of EXIST G 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- ' 0 3, 51-`83 ness and Professions Code): NO. PARKING SPACES PROVIDED I, as owner of the property, will.do the work and the structure isnot intended or offered for sale (Sectio �77,3 7044, Business and Professions Code). PROPOSED use of BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for x Xhich 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 or inances and State laws relating to building construction, TOTAL FEE a d hereby authorize representatives of this County to enter on above-mentioned property for inspection purpWes. SEE REVERSE FOR EXPLANATORY LANGUAGE •gna u e f ermi a Date`\ WORKERS'COMPENSATION DECLARATION CE 876(2-80) MISCELLANEOUS APPLICATION 1 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. BUILDING 1� ADDRESS LOCALITY �j OS"�� ❑ Certified copy is filed with the county building inspection NEAREST department. Loc LITY ., L CROSS ST. Date Applicant REST DISTRICT NO. G UP TYPE PROCE ED BY Lo CROSS ST. ,. `{I CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (� COMPENSATION INSURANCE DESCRIPTION L T NO. BLOCK 'MAP 7HIGHWAY STATE MAJOR SEC D LOCAL NO. (CIRCLE) Q. NO. OF BLDGS. O (This section need not be completed if the work involved TRACT NOW ON LOT USEJZjONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) /�USE TI / ' SIZE OF LOT EXISTING BLDG. 1`/ Cr 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 Laws. NER -� 1-- so so as to become subject to the Workers' Compensation Laws. AIL (//-' J gy J� OCCUPANCY GROUP I yst„�' tL AD ESS f� i�hN(�J '1 r .. a Date ApplicantIL N NOTICE TO APPLICANT: If, after making this Certificate of clrY �. 3T 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 deemed revoked. ❑ No Spec. Knowl. ❑ Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY' INSPECTION 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- I ness and Professions Code, and my license is in full force and PARKING effect. SPACES REQ'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 : IN PE CTO R'S acting ,in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES GNATURE ines'sand Professions Code). FINAL APPROVAL RESENT USE OF BUILDING J / Y Lic.or Reg.No. Date •.• HOME OWNER-BUILDER DECLARATION NO. OF EXISTI6NG BUILDINGS / L Q ON LOT AND USE 0 4.1. 8 5 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): SPACES PROVIDED ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). ROPOSED 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 upory the above-mentioned property®toy mion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SignatureolWermittee Date ^Av WORKERS'COMPENSATION DECLARATION CE 8754(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. CompanyFOR APPLICANT TO FILL IN BUILDING ❑ ADDRESS 11 Certified copy is hereby furnished. BUILDING ADDRESS 131-116 LOCALITY C ' ]�'�� N /C��/yG/T'D Certified copy is filed with the county building inspection NEAREST department. LocwLirY { CROs sT. Date Applicant NEAREST DISTRICT NO. O P TY / PROC SED BY CROSS ST. }/�� C ST. / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ✓ v I/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP l) "IGH-AV , No. 3 (CIRCLE) STATE MAJOR SECOND LOCAL Q.. (This section need not be completed if the work involved NO. of BLDGS. USE ZONE SPECIAL CONDITIONS ®_ P. ' TRACT NOW ON LOT U by the permit is for one hundred dollars ($100) or less.) USE OF /n' I certifythat in the SIZE OF LOT EXISTING BLDG. C.. performance of the work for which this permit is issued, I shall not employ any person in any manner wNER m(' �iSl� lw1 ~ so as to become subject to the Workers'Compensation Laws. MAIL p OCCUPANCY GROUP U DDRESS U' 130 3 fL Date Applicant U) rEL.P/3� OCCUPANT LOAD Z NOTICE TO APPLICANT: If, after making this Certificate of cIT.Y. No. �7-0 }�' 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. El No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONPanic Devices El I hereby affirm,that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 PARKING. effect. SPACES REQ'D PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE . -• F R O M TO: I 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 mess and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING g � p�j J 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 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 pz 1 .372 A 7044, Business and Professions Code). ROPOSED USE OF BUILDING �Z�AyJ/�� 9. p O CJ (/F G/c O O.O O O CONSTRUCTION LENDING AGENCY '' ' ' I hereby affirm that there is a construction lending agency o 00 0 0 0 o z for the performance of the work for which this permit is ' ' ' ' issued(Sec. 3097,Civ.C.).. 09,29-81 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 _G.✓, Q� pon the abo e-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee ate WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C AT I O N 1 hereby affirm that I have a certificate of consent tself CE 875 (11-84)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 / ^ ADDRESS 4N. Y) Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST D DISTRICT N GROUP TYPE OCESSED BY CROSS ST. ' /� // CONST: - CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v K COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NOOF 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 I certify that in the performance of the work for which this SIZE OF Lor EXISTING BLDG. 0 permit is issued, I shall not employ any person in any manner OWNER dez.-�/wd , "' so as to become subject to the Workers' Compensation Laws. MAIL 7 �I�? n /� OCCUPANCY GROUP a DDRESS J W •,i14,0 �ko Date Applicant j UJ NOTICE TO APPLICANT: If, after making this Certificate of CITY/15;M,--;/-6� OCCUPANT LOAD Q_ 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. 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 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 r - LIMITED TIME USE Contractor Date DATE DATE PROM: 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 SIGNATU E iness and Professions Code). ' �� ,/� FINAL APPROVAL Lie.or Reg.No. Date PRESENT USE OF BUILDING T✓U /C HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING NO FEE 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 CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING � �f fe 5747 1 F,1 04 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 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 hergby authorize representatives of this County to enter TOTAL, FEE 0 Q up n e above-mentioned property for inspectiO7 purp ses. 1 SEE REVERSE FOR EXPLANATORY LANGUAGE _ 9 ` Signature o Permittee ate WORKERS'COMPENSATION DECLARATION .76M444 875 (11-84) MISCELLANEOUS APPLICATION CE 875 1 hereby affirm that 1 have a certificate of consent 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.). FOR APPLICANT TO FILL IN BUILDING Policy No.. Company ADDRESS Certified co is herebyfurnished. Bu1LDING (/ ^j p} XY ADDRESS 63% LOCALITY ElCertified copy is filed with the county building inspection LOCALITY NEAREST department. 3CX CROSS ST. Date---Applicant NEAREST (� DISTRICT NO. GROUP TYPE P OCESSED BY _ CROSS ST. CONST../I/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COM PE•.NSATI ON INSURANCE DESCRIPTION LOT NO. BLOCK MAP ..-AY NO. (CIRCLE) 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 SIZE OF LOT EXISTING BLDG. 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manne3CX OWNER of buildin I v so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS I , Date----- Applicant — 9 4. TEL. OCCUPANT LOAD NOTICIC TO APPLICANT: If, after making this Certificate of CITY No. u 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. OCCUPANCY INSPECTION Panic Devices LICENSED CONI RAC"DORS DECLARATION _ I hereby affirm that I :lin 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 art*X effect. Name of business PARKING REQ D PROVIDED L SPACES ,tel License Number Lic. Class rec 5 O e �� LIMITED TIME USE Date DATE DATE FROM: TO: I am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer SIZE OF NO. OF— INSPECTOR'S acting ill niy professional capacity (Section 7051, Bus- EXISTING BLDG. b /o0 ( STORIES � S NATURE inessand Professions Code)' 1 '164FINALAPPROVAL Ilk /.�✓ PRESENT USE OF BUILDING J Lic.or Reg. No, _ Date — 11011E OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 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- IteSS and Professions Code): NO. PARKING ❑ 1, as Owner of the SPACES PROVIDED 1, will do the work and the . (.t,f„ j r?{i's._='•.~''' structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING 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 certify that 1 have read this application and slate 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 CQunty to enter TOTAL FEE 25-00 upon the ab(1mentioned property for inspectio)kurposes. 1 SEE REVERSE FOR EXPLANATORY LANGUAGE r XX 0 ------- – ------------ — �irn;�lnn• � I''rn�i�lc•r I :Ile i VOR:ERS'COMPENSATIONDECLARATION 3 CE i11-84) MISCELLANEOUS APPLICATION 1/7 C5 875 I hereby_ afrttm that I have certificate of consent tself COUNTY OF LOS AiNGELES BUILDING AND SAFETY DIVISION ,tttllfLLL��lljljljl 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 ADDRESS Co F7Certified copy is hereby furnished. g, AU IL IN e LOCALITY I Certified copy is filed with the county building inspection X LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP IT Y PE��a� CESSED BY CROSS ST. n� CON CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (/ 3 COMPENSATION INSURANCE. DESCRIPTION LOT NO. (3L0 CK :Hwv .1—AY I NO. OF SLOGS. [CIRCLET STATE MAJOR SECOND LOCAL n0. (This section need not be completed if the work involved 1 TRACT ;NOW ON LOT USE TONEISPECIAL CONDITIONS by the permit is for one hundred dollars (S 100) or less.; SE OF /J SIZE OF LOT 1 EXISTING SLOG. O� - I certify :hat n the performance �f :he vorc 'or ',vhich this _ permit is issuea. I shall not empiov any person T.,any manner x ' � p OWNER so as to become subiect to the Workers' Compensation Laws. HAIL — CCC 1PANCY CROUP = Date Appiican? g AD OR Ess ~ ifE 7� NOTICE TO APPLICANT: If, after making _his _^;fi ate Of g � -.-. '� �/� �cL / � CCCUPAN7 -CAC I E.,:emption. you should 'become subject to the Wor.:e,s' _ Compensation provisions of the Labor Code. you must torah- gad _7 PP.-ICA7CN FOF � =;<I' .AnC'wARE: � I..1 comply with such provis:ons or this hermit :ilei ''e I-RAIL.R USE — -ECLCGY :N SPECT'CN = � NC I -evckzd. i _ OCCUPANCY ::,SPECT:C: T Panic Devices LICENSED CONTRACTORS DECLARATION I herebv affirm -hat I am [}censed under provisions of Chapter ,aF^TY SR`A T �I- — LIS !TS BELOtYT 9 !commenclmz with Section 7000) of Division ', of the Bus: - EI No. OF EXI?s ness and Professions Code, and m� license is in full force and 2: ect. PARKING REO'D I PROVIDED II ,n SPA C.S License Number L}c. Class E i = LIMITED TIME JSc I Contractor Date tQ C [ am exempt from :he icensi m a i -� n_ requ;remeats .is INSPECTOR'; licensed architec ! , or a -e,Isterea <ororessional "nzirter srzOF No. CF i ,IGNar R acting in my professionai caoac;tv �Sec:ion 0-4 i. :S is S_ .c:S-;;JG 3LCG. ST OR!ES iness and Professions Code). i FIN a L APP R O VA L A I PRESENT :OSE OF 3L'I171NG _ Lic.or Re_;. No. Date 1IIIPPPP HOt%4E OWNER-BUILDER DECLARATION NO. of EXISTING BUILDINGS I I p . ON 1-37 AND USE ill/// I hereby ii.`i n that i im exempt from :'tie Co lt:acmr s ! to L:cense Law for the 'oilowing season (Sec,ion 70'1. . 3usi- ! I ness and Professions Code): NGPA. PAS ?RKING 11i SCEROVID E7 .. ;-•...._. ... . I. as owner of the grocer:v, %viil do -he %vcr:: _na structure is nor intended or offered for saie (Section 7044.Business and Professions Code). ?` CONSTRUCTION LENDING AGENC`: x PROPOSED USE OF BUILDING l�I Hereby affirm that there is a construction ':ending 'agenc;: T ! for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lenders.address 25.00 I certify that [ have read this application and state that the PERM]—. FEE above information is correct. I agree to compiv with all County I 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-mentio d property for inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of per i*see Dztz