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HomeMy Public PortalAbout6404-6414 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION CE 875 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.Q. IWO Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS Certified copy is filed with the county building inspection LOCALITY �S 'g1 D�(7t�n. �2V� `li VV ��CJ�_�� NEAREST department. . CRosS ST. Date Applicant EAREST fa ' 0rNC �.pt {moi/yJ-, DIST, G P TYPE PROC SSE D BY CROSS ST. �(,J NL.�0.fV ✓ •IU CONST. ` CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP MIGNWA NO. F BLDGS. I rvo. (CIRCLE) STATE MAJOR SECON')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 I certify that in the performance of the work for which this SIZE OF LOTpp EXISTING BLDG. permit is issued, I shall not employ any person in any manner OWNER Rv�� g /,Q nj so as to become subject to the Workers' Compensation Laws. AIL `OCCUPANCY GROUP. DRESS o s\•'�. `.. J &2 Date Applicant c3 TEL. LV NOTICE TO APPLICANT: If, after making this Certificate of CITY No �\ �j. p 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 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 REQ'D D PROVIDED D 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 INSPECTORS acting in professional capacity (Section 7051, Bus XISTING BLDG. STORIES SI ATURE iness and Professions Code). Nl 11 n�[ ^� FINAL APPROVAL Lic.or Reg.No. Date PRESENT USE OF BUILDING 171L„ ct� 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 0 I, as owner of the property, will do the work and the SPACES PROVIDED # 0 0 D 0 zJ0 structure is not intended or offered for sale (Section �( L/ 7044,Business and Professions Code). �T � 230-86 z CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 1t 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 ' I c that I have read this application and state that the abo rmation is correct.I agree to comply with all County ISSUANCE FEE ord' nc and State laws relating to buil 'ng construction, and authorize r resent atives of thi County to enter TOTAL FEE iy�o n ' ro erty for ins p ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE J Signature of Permittee bateI WORKERS'COMPENSATION DECLARATION 76M444 �.. CE 875 (11-84) MISCELLANEOUS APPLICATION {� I hereby affirm'that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Ll 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 6408 ROSEMEAD B.LVD LOCALITY ADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRIGy.yO. O P TYPE PRO SSED BY CROSS ST. LONGDEN ST l///YL?JI[ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 5. COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NO. F BLD GS. NO. (CIRCLE) STATE MAJOR SE ND 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 i d I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. C:3 permit is issued, I shall not employ any person in any manner OWNER T A M A R A N P R O P E R T I•E S E so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o DDRgsS 9.9-Q ORLANDO SAN MARINO 11 Date .Applicant NOTICE TO APPLICANT: If, after making this Certificate of CITY 91108 NOL 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 INSPECTIONNo Spec. Knowl. deemed revoked. 1-1 Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM fLIST 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 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 INSPECTORS acting in my professional capacity (Section 7051, Bus XISTING BLDG. STORIES SIG ATURE iness and Professions Code). FINAL APPROVAL _ PRESENT USE OF BUILDING Lie.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 8 3 9,b.A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 0 I, as owner of the property, will do the work and the SPACES PROVIDED # O O O • 8 structure is not intended or offered for sale (Section D o D O a,e o z 7044,Business and Professions Code). IV PROPOSED USE OF BUILDING .1 .1,2o-87 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency As an offfte for a referral for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. service t 0 business e 0 l e Lender's Name in genera PROPOSED MAX. OCC. Lender's Address �� 1 1 I certify that I have read this application and state that the PERMIT FEE Uk V � /1 above informattt. ct.I agree to comply with all County ISSUANCE FEE ordinances andws re ngto building construction, �.and hereb ares t Ives ofthis County to enter TOTAL FEE Q� 6Von the od erty for insp tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE /o - W-f7 ature o mittee Date WORKERS'CQMPENSATIONDECLARATION CE 875(11-84) M ISCELLANEOUS 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(See. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING LV/\ ADDRESS ■Vl Certified copy is hereby furnished. Be DRESS nn G� � !>a�v LOCALITY / ADDRESS� {/,,r Certified copy is filed with the county buil ing inspection LOCALITY 2� NEAREST department. S/�ry /�L CROSS ST. Dat Applicant NEAREST / / DI$SA:C� Ko3 YPE P ES BY CROSS ST. D/V,ci �/`� `//�) U C NST. C TIFICATE OF EXEMPTI/dlars WORKERS' LEGAL COMPENSATION[ E DESCRIPTION LOT NO. BLOCK MAB HIGHWAY rvo. (OIRCLE) ATE MA OR CO LOCAL NO. OF BLDGS. (This $QCt n need not be compe Work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the per it is for one hund ($100) or less.) USEof SIZE OF LOT EXISTING BLDG. I certify that the performancerk for which thispermit is issued, shall not emplon in any manner OWNERso as to become ubject to the Wpensation Laws. �O y OCCUPANCY GROUPcc ADDRMA'LESS X IrC. � ��, O � 3 Date pplicant lyl TEL �'� P_grq OCCUPANT LOAD NOTICE TO APPLI NT: If, of r making this Certificate of CITYq�/ No. R7 z Exemption, you sho Id beco e subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisio of th Labor Code, you must forth- with comply With sucl prov ions Or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Ky�owi. deemed revoked. �/ LICENSED CONT TORS DECLARATION OCCUPANCY INSPECTION Panic Dev es I hereby affirm that I am li nsed under provisions of Chapter SAFETY PERMI LIST ITEMS BELOW) 9 (commencing with Sectio 7000) of Division 3 of the Busi- NO. OF XITS ness and Professions Code, n my license is in full force and Ir O� �S effect. L PARKING / SPACES RE �D PROVIDED License Number Lic. Class G ���r�G G LIMITED TIME USE Contractor ate I DATE DATE I am exempt ft the licensi requirements as I am a FROM: TO: licensed archite t or a registe d professional engineer SIZE OF NO. OF INSPECTORS acting m my rofessional capa 'ty (Section 7051, Bus- EXISTING BLDG. g 5 _ STORIES SIGNATURE inessand Prof sionsCode). FINAL APPROVAL PRESENT USE OF BUILDING (J Lic.or Reg.No. ate i HOME WNER-BUILDER DECL RATION NO. OF EXISTI Bu . .INGs �_9 ON LOT AND USE I Hereby aff' that I am exempt from he Contractor's License Law or the following reason (Secti 7031.5, Busi- ness and Pro essions Code): NO. PARKING ((( 0LiW(00�i Tf./i41� i 4'i i � ❑ I, as wrier PROVIDED er of the property, will do the vork and the fi ,— stru re is not intended or offered for ale (Section 0201= 1 Pim 7:30 704 ,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING V%- 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, O and hereby authorize representatives of this County to enter TOTAL FEE 7upn the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION �E 8754(11-84) MISCELLANEOUS A P P L I C A T I O N I herby 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.). Nan BUILDING Policy o. Com O P Y FOR APPLICANT TO FILL IN ADDRESS Certified copy is hereby furnished. BUILDING 4 LOCALITY ADDRESS 1 V , Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE CESSED BY CROSS ST. ,ml fir, 'oV CON CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL 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 (5100) or less.) /^� USE OF V SIZE OF LOT ( L 0 0 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 �� / o so as to become subject to the Workers' Compensation Laws. MAIL nn OCCUPANCY GROUP i1 a ADDR ES I V 0O^ - Date Applicant uJ NOTICE TO APPLICANT: If, after making this Certificate of CITY 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 ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code, and my license is in full force and - effect. � PARKING \ SPACES REO°D D PROVIDED O License Number Lie. Class rX AA L1, 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 INSPECT R'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. D V STORIES SIGN RE iness and Professions Code). I FINAL APPROVAL PRESENT USE OF BUILDING Lie.or Reg.No. Date I t— &__� [ 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- USS ness and Professions Code �;7 ): NO. PARKING - ❑ I, as owner of the property, will do the work and the SPACES PROVIDED /y ° 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 U for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). Ch Lender's Name PROPOSED MAX. O C. Lender's Address I certify that I have read this application and state that the PERIT F above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, r and hereby authorize representatives of this County to enter TOTAL FEE upon the above-mentioned property for inspectio purposes. IV/ / SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee ✓ D e 1 WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES - BUILDING AND SAFETY DIVISION insure, or a certificate of Workers,Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No: � � Company FOR APPLICANT TO FILL IN BADDUILDREING ❑ Certified copy is hereby furnished. BUILDINGMla* LV LOCALITY OCertified copy is filed with the county building inspection - ADDRESS s NEAREST department. LOCALITY T p_j _ a / CROSS ST. Date Applicant AREST 1 (fig+ y, DISTRICT NO GRO P YPE PRO SSED BY CROSS ST. 11-- .R4� �vIC u CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK "Al HIGHWAY } NO. F rvo. �r:3 (CIRCLE) STATE MAJOR SECOND LOCAL d BLDGS. (This section need not be completed if the work involved TRACT NOWOON LOT USE.ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. ^' it I certify that in the performance of the work for which this Q permit is issued, I shall not employ any person in any manner WNERPtkK iAc. — Pt"LA U so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP tL Date Applicant ADDRESS �' �'}� /}'U( MR• �cTi co Z NOTICE TO APPLICANT: If, after making this Certificate of CIrY I Z "V No. �' OCCUPANT LOAD Exemption, you should become subject, to the Workers' SAPPLICATION FOR XIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with-comply with such provisions or this permit shall be deemed revoked. TRAILER USE GEOLOGY INSPECTION 0 No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT La (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and PARKING effect. SPACES REO'D O PROVIDED Lil-ense Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE aI am 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 SIGNATURE iness and Professions Code). FINAL APPROVAL RESENT USE OF Lic.or Reg.No. Date UILDING v 1 HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS oN Lor AND u;E I hereby affirm'that,.I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- 4 2 9,6 A ness and Professions Code): NO. PARKING SPACES PROVIDED I, as owner of the property, will do the work and the #'a(a'o o 8 8 structure is not intended or offered for sale (Section •9( 0 LQ 7044, Business and Professions Code). OPOSED USE of BUILD IN ���� •IIM;-T 109. ,2 84 CONSTRUCTION LENDING AGENCY �-� %�1��+6 I hereby affirm that there is a construction lending agency L Awwr , � 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 Up he above-mentioned ope•ty f r inspectiol purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Ignature of Permittee Date WORMERS'COMPENSATION DECLARATION a CE 875 (11-84) MISCELLANEOUS APPLICATION CE 87 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 ADDRESS Certified copy is hereby furnished. BUILDING yI, u�/ /f ^ LOCALITY ADDRESS ' �f�N{! `- -�- ElCertified copy is filed with the county building inspection /y� LOCALITY NEAREST department.. / �'Q G- CROSS ST. Date Applicant NEAREST DISTRICT NO 6R UP TYPE f P CESSED BY � CROSS ST. rf jeIa,Ile— CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V v COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NO. F BLDGS. 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 SIZE OF LOT EXISTING BLDG — Icertify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manner OWNER q.&� 2oP £ `D so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP z MAIL ADDRESS ® eJ 4-"1)a � , 2�i] I-- Date Applicant LLI TEL' OCCUPANT LOAD o NOTICE TO APPLICANT: If, after making this Certificate of CITY l� NCI JV1 r ..0!f/_3 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 ❑ 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) 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 D PROVIDED SPACES License Number Lic. Class C% Z" s 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 INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). /aCN r FINAL APPROVAL CZz ?L PRESENT USE OF BUILDING J Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE /I l� '` '-' - •-�••^•• I hereby affirm that, I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness usi ness and Professions Code): No. PARKING •,. SPACES PROVIDED R I, as owner of the property, will do the work and the f i_ r ,,,•,w, 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.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE I above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon the above-mentioned property for inspection purposes. :F?— , SEE REVERSE FOR EXPLANATORY LANGUAGE Signat of Permittee &17 Date WORKERS'COMPENSATION DECLARATION if CE s4 54( 2 80) MISCELLANEOUS APPLICATION I heiehy 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 ther.of(Set%:3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ ` Certified copy is hereby furnished. uILDING �'t r `I Ps.t „�A G� LOCALITY ADDRESS T /v it Certified copy is filed with the county building inspection ! �p�- department. LoeALITY �G,C 01/ CROSS sT. Date ApplicantNEAREST DISTRICT NO. O P TYPE PRO SED BY ROSS ST. �'. �"- CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V7 L DESCRIPTION LOT NO. BLOCK } COMPENSATION INSURANCE, NO. (CIRCLE) STATE MAJOR SECO LOCAL IL P TRACT NOW ON LOT (This section need not be completed if the work involved NO. of USE ZONE SPECIAL CONDITIONS 0 OT by the permit is for one hundred dollars ($100) or less.) USE OF cc SIZE OF LOT EXISTING BLDG. 0 I certify that in the performance of the work for which this O permit is issued, I shall not employ any person in any manner OWNER �/� /� ��1/ri 71 IV (� U so as to become subject to the Workers' Compensation Laws. V „ 1 !J /A1 .,/yam/ OCCUPANCY GROUP II MD DRESS / /(6 �[/. •• CL Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of ciTY eI ^/ Cn �. Noi. 21 OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION deemed revoked. ❑ No Spec. Knowl. 0 AULICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and PARKING. I�� effect. REO'D I I PROVIDED D SPACES �1 License Number Lie.Class LIMITED TIME USE Contractor Date DATE DATE ❑ FROM: TO: I am exempt from the licensing requirements as I am a. licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES GNAT U RE Ine$S and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lie.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 2129. 1 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING {{// e-088 Q Q SPACES PROVIDED # a 8 v 1,-as owner of the property, will do the work and the o s • s o s • structure is not intended or offered for sale (Section 7044, Business and Professions Code). Q C PROPOSED USE OF BUILDING O 1. O 2-8 J 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 1 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' n y-� and hereby authorize representat' e of this County to enter I✓ (-jam d, � 1 upon t eabove-mentioned pro r for inspection purposes. SEE REVERSE FOR EXPLANATORYIrI_, UAGE J ignature ofitte DatOre WORKERS'COMPENSATION DECLARATION CE 875(2-80) M I SC E L LA•N E O U S 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. uILDING) gyp-��y 0 / ��� -9 LOCALITY ADDRESS (p K 1-I 717��t v V Certified copy is filed with the county building inspection '. NEAREST department. LOCALITY ! lj :S C, CROSS ST. Date Applicant AREST \ /� A DISTRICT RO PEJP:W SED BY CROSS ST. !L//l1 -1/Y CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAV HIGH WAV .. NO. � � (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. d (This section need not be completed if the Work involved TRACT NOW ON LOT USE ZONE rIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) usE of U SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this cc permit is issued, I shall not 'employ an Q p p y y person in any manner WNER 1 v so as to become subject to the Workers' Compensation Laws. AIL /�� ` V 1 OCCUPANCY GROUP U Date Applicant ADDRESS KO� �i �� V\�rrj LWL TEL.r Cn NOTICE TO APPLICANT: If, after making this Certificate of CITY �j No.t$t`�')Zb�ol� 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. ❑ ❑ No Spec. Knowl. OCCUPANCY INSPECTION�"- Panic Devices LICENSED CONTRACTORS DECLARATION _ Iahereby affirm that I am licensed under provisions of Chapter swFErY PERMIT (LIST ITEMS BELOW) NO. OF Exlrs a 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect. PARKING REO'D � PROVIDED SPACES 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). J. FINAL APPROVAL ,,,rrrr..yyy�yy � . P ENT USE OF BUILDING © • /�7a Lic,or Reg.No. Date tv II// HOME OWNER-BUILDER DECLARATION. NO. OF EXISTING BUILDINGSON LOT AND USE I hereby affirm that- I am exemptfrom the Contractor's License Law for the following reason (Section 7031.5, Busi-. 222 77 A ness and Professions Code): NO. PARKING SPACES PROVIDED - 1, as owner of the property, will do the work and the # 00 0 o 88 structure is not intended or offered for sale (Section i I w 7044, Business and Professions Code). 0 o.0' 0 0.0 o z OL POSED USE OF BUILDING /'1 Q 6� M /I-r� CONSTRUCTION LENDING AGENCY `/6, /I'I (/l 0 6 2:b—8.4 1 hereby affirm that there is a construction lending agency for the performance of the work for wJiich 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'for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ��- c� ✓ s- Signature of Permittee ate t WORK. RS'COMPENSATIONDECLARATION CE 875(1 t-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 /_���/ �� / CA - f ADDRESS (� (� c Certified copy is hereby furnished. wooeess pLiQ lJ, LOCALITY Certified copy is filed with the county building inspection LOCALITY C � NEAREST department. sr .U '� Date Applicant NEAREST vSA� DIST NO, GROUP TYPE / P CESSED BY CROSSST. r Da(/ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Y COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NOOF BLDGS. (This section need not be completed if the work involved TRACT NO. OF ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) JUS E OF SIZE OF LOT EXISTING BLDG. } I certify that in the performance of the work for which this of �r o permit is issued, I shall not employ any person in any manner OWNER XA tl✓IA) so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ® o ADDRESS Date Applicant / �n NOTICE TO APPLICANT: If, after making this Certificate of CITY��T1v 1 d\no TNOCCUPANT 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 deemed revoked. TRAILER USE ❑ GEOLOGY INSPECTION ❑ NO Spec. Know[. 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 n I� e effect. a -v 6 PARKING REQ'D PROVIDED C � 1 _J License Number Lic. Class SPACES 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. INSPE CTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING �-0� FINAL APPROVAL Lie.,or Reg.No. Date f HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE CH1{10—fll-j-1 y I yy, I hereby affirm that I am exempt from the Contractor's - c 7 I ,; i License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING �J 0 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 '&,r I hereby affirm that there is a construction lending agency v\ "-,!I I for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). L Lender's Name I I' • PROPOSED MAX. OCC. Lender's Address I PERMIT FEE I certify that I have read this application and state that the above in tion is correct.I agree to comply with all County ISSUANCE FEE ordina es a d State laws relating t building construction, and h reby uthorize r sen ati es of this Count. to enter TOTAL FEE upon the e-menti roe y or inspectio SEE REVERSE FOR EXPLANATORY LANGUAGE 1�� ignature o ermittee Date Jf 11 WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'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. UILDING LOCALITY O ADDRESS Q 94 Certified copy is filed with the county building inspection NEAREST department. &,LOCALITY CROSS ST. Date Applicant NEAREST DISTRICT N GROUP TYPE IPROCE SED BY SS ST. ���+ CONST.. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL F COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY } _ NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF SLOGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O by the permit-is for one hundred dollars ($100) or less.) USE OF V SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this c O permit is issued, I shall not employ any person in any manner OWNER U so as to become subject to the Workers' Compensation Laws. M IL v OCCUPANCY GROUP w DDRESS !40 0- Date- Date Applicant to NOTICE TO APPLICANT: If, after making this Certificate ofd Tv No. 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 su deemed revoked. ch provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION❑ ❑ 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 effect. PARKING.SPACES REO'D PROVIDED 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- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). G- .PRESENT USE OF BUILDING" FINAL APPROVAL ��l� G (• Lie.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- ?2 8 5.7 A SP ness and Professions Code): PARKING SPACES.PROVIDED 1, as owner of the property, will do the work and the #1010.0'o 8.8 structure is not intended or offered for sale (Section 0 0 0 7044, Business and Professions Code). 0 0 WOPOSED USE of BUILDING I0;0 to I . CONSTRUCTION LENDING AGENCY 0 7,'2 0,—8 4 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 hr by authorize representatives of this County to enter -m nti ned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 17�- ISignature of Permittee Date 1 WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,or a certificate of Workers'Compensation Insurance,or a certifie ' � 0f Y P Y FOR APPLICANT TO FILL IN BUILDING ADDRESS / ❑ Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS "} J •/ ~ ❑ Certified copy is filed with the county building inspection NEAREST department. LocnLlTv 1CR.SS ST. Y' ' pate Applicant NEAREST DISTRICT,,NO. GRp� TYPE PRO,- SSED BY CROSS ST. %- CONS' ;. a CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL C DMIGM WAY ESCRIPTION LOT NO. BLOCK COMPENSATION INSURANCE NO (CIRCLE) STATE MAJOR SECOND LOCAL U NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS tL by the permit is for one hundred dollars ($100) or less.) �:A J p USE OF SIZE OF LOT EXISTING BLDG. LL 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. -MAIL J/)i OCCUPANCY GROUP ADDRESS �!�• } Date Applicant f t O NOTICE TO APPLICANT: If, after making this Certificate of 4 CITY i'''`i t' �+ No� OCCUPANT LOAD t1 Exemption, you should become subject to the WorkersAPPLICATION FOR EXIT HARDWARE: 4U 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 INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEMS BELOW) ❑ No. of EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code, and my license is in full force and PARKING • effect, SPACES REO'D PROVIDED,� ,�f a •� 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 ST OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date- HOME ate 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- }( 1. a c, 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 ri 7044, Business and Professions Code). Q 3 �! PROPOSED 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 r ...% and herpy authorize representatives. of this County to enter upon the above-mentioned proper`q for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Perrriittee Date I -