Loading...
HomeMy Public PortalAbout4805 TEMPLE CITY BLVD_Miscellaneous__ • WORKERS'COMPENSATIONDECLARATION CE 876 11184)44 MISCELLANEOUS APPLICATION {1 CE LJ 1 mom, o affirm cert that 1 have a s Come of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, qr a certificate of Workers Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN BmLoDR¢BBrrvG 6D�- wDJ Q Certified Copy is hereby furnished BUILDING 4 4Z ADDRESS 4805 TEMPLE LOCALITY _ ElCertified Copy is filed with the county budding inspection LOCALITY neva Ear department TEMPLE esu o¢a ST Date Applicant Ne ARBST �ryry�'�rC�,,pr, DISTRI T NO O oUE rYe¢ Ce¢5¢D er c11 o¢O ST LJD r' ,rn O r _ �] CON¢r CERTIFICATE OF EXEMPTION FROM WORKERS' LaGwL O Os COMPENSATION INSURANCE D¢9CR IPTION LOT No BLocK MAP w%CLi) STATE MAJOR SECOND LOCAL (Thu section need not be completed if the work involved No Or RLDoa A p TRACT Now or Lor ], u¢Q zon¢ areeuL CONDITIONS by the permit is for one hundred dollars 1$100) or less) uaE DF I certifythat in the ¢¢e OF Lor UK X, IND BLDG performance of the work for which this 1 11 permit is issued, 1 shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws _ MAIL OCCUPANCY GROUP 6lOs o Date Applicant ADDRES W NOTICE TO APPLICANT If, after making thus Certificate of CITY'S No 1 OCCUPANT LOAD D_ Exemption, you should become subject to the Workers' 19 Compensation provisions of the Labor Code,you must forth- P KATION FOR /lbs" EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER USE deemed revoked P o¢oLoot INSPECTION Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT (LIST IT¢MS BLOW) 9 (Commencing with Section 7000) of Division 3 of the Busy No OF BAITS ness and Professions Code, and my license u in full force and effect f.,e - PA RKIRB SPp CBB RQOO D PROVIDED D License Number Lic Class LIMITED TIME USE Contractor Date DwTa DwT. DI am exempt from the licensing-requirements as 1 am a P,.oM To licensed architect or a registered professional engineer slzQ of ND or - Tow a acting m my professional capacity (Section 7051, Bus- QAISrINo BLDo 915 E.Q. ft. STORIMS 1 SIGN Re mess and Professions Code) RESTAURANT FINAL APPROVAL PRESENT VS¢ OF BUILDING 7Q Lic or Reg No Date 19't HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS rE]C• 1 'CI :CIY ON LOT AND am 1 GI� I hereby affirm that I am exempt from the Contractor s � License Law for the following reason (Section 7031 5, Busy ' ness and Professions Code) NO PARKING ❑ 1, as owner of thePe ro rt will do the work and the SPA.MS PRov ID¢D ✓�� P structure is o not intended or offered for We (Section _ 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED VSB OF BUILDING RESTAURANT _ 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 Bee Lender's Address 1 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 budding construction, Oa and hereby authorize representatives of this County to enter TOTAL FEE upon the ve mentioned property for ms ec on purposes SEE REVERSE FOR•EXPLANATORY LANGUAGE Signatur of Permittee Date I I WORKERS COMPENSATION DECLARATION CE 875 l2 801 MISCELLANEOUS APPLICATION CE 876 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 wooecae ❑ Certified copy is hereby furnished BUILDING 91114 -}' LOCALITY Certified copy Is filed with the county bmldmg mspecton �e NEA RE department LOCALITY CA r CROSS ST O.wL(/(i Date Applicant NEARS ST DISTRICT N o OUP rY PH PRoc Serer .CROSS'BT '� CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL Y COMPENSATION INSURANCE DESCRIPTION LOT No eLOcx11 .NjuRUSI STATE MAJOR SECOND LOCAL >_(This section need not be completed if the work involved TRACT NrvO OF oLDOS Q. ow ON LOT USE ZONE SPECIAL CONDITIONS O by the permit Is for one hundred dollars (S 100) or less) use or U 1 certifythat In the SIZE OF LOT HxISTING RLDO G/ performance of the work for which this 1 ' ¢¢ permit u Issued I shall not employ any person to any manner OWNERCompensationV N U so as to become subject to the Workers Compensation Laws AIL OCCUPANCY GROUP �� ADDRESS W Date Applicant d //.. N NOTICE TO APPLICANT if after making this CertiflCetL Of CITY { 1.�� wo I 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 GEOLOGY INSPECTIONNO $ BC KnOWI ❑ deemed revoked P LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 0 Panic Devices ❑ 1 hereby affirm that I am licensed under provisions of ChaptLr SAFETY PERMIT q (LIST ITEMS BELOW) NO OF EXITS 9 (commencing with Section 7000) of Division 3 of the Bust nms and Professions Code and my license Is in full force and PwRxINa effect SPADES RHO D PRoviDeD License Number Lie Class LIMITED TIME USE Contractor Date DwTS DwTS F11 am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineLr sae OFINSPECTOR a acting in my professional capacity (Section 7051 Bus EXISTING BLDG "o OrS eiarvwruwe No o• mess and Professions Code) 11 RHIHFINAL APPROVALNT USE 0I BUILDING Lie or Reg No Dale HOME OWNER BUILDER DECLARATION NO o Ex18T1 O BUILDINGS 'NO LOT AND USE I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Bust nese and Professions Code) NO PARKING SPACES PROVIDED ❑ I, as owner of the property will the work and the 0 8 Z 0 A structure is not intended or offered for sale (Section - 7044 Business and Professions Code) 00 ROPOSHD USE OF BUILDING # • • • • 88 CONSTRUCTIgN LENDING AGENCY I ( �/'i • • •4 S A S I hereby affirm that there is a construction lending agenLl �-! for the performance of the work for which this permit Is g 1 9-81 issued (Sec 3097 Cly C) Lenders Name PRovoseD MAX occ Lender's Address PERMIT PEE 1 certify that 1 have read this application and state that on above Information Is correct I agree to comply sslth all County ISSUANCE FEE �,.„ ordinances and State laws relating to building my to erste TOTAL FEE 5 OD �/G�(// and hereby authonze re sentetves of this County to enter OA. the above mention property for inspect purposes E REVERSE [OR CXPLANATO Y LANGUAGE / r ore of rmI Date WORKERS COMPENSATION DECLARATION CE 875(2 BO) MISCELLANEOUS APPLICATION {� CE 876 LJ Tint erefe of 9 certificate of Workers 4rthat I have a eCompensation Insurancertificate of consent to self or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION e certified copy thereof(Sec 3800, Lab C) Policy No Compan) FOR APPLICANT TO FILL IN BUILDING O TP'ru [Z C(Tr B L ADDR¢e{ ❑ Certified copy is hereby furnished uuOl Nc Q-' 7� Ll- C(rr LOCALITY ❑ d ADDR688 Certified s filed led with the county building inspection NEAREST department LOCALITY Q/ �Z C/Tr cwoae aT /-owab Aziir4 go Date Applicant RASESr /_ DISTRICT a ouP TYPE PROs s¢D BY CROS{ 8T IDW 2aS I c ONYT CERTII KATE OFI EXEMPTION FROM WORKERS' LEGAL J' COMPENSATION INSURANCE DESCRIPTION LOT(No 'Loc. MAP ",onwA } no of eLDas _ (ciwcc.l STATE MAJOR t¢ NO LOCAL a (Thu sec[ron need not be completed If the work involved ' TRACT NOiS ON Lor USE zone SPEUAL comm�owa U by the permit is for one hundred dollars ($100) or lea) USE TI �� SEE oP LOT cxiannc BLDG 1 certify that m the performance of the work for which this permit u Issued I shall not employ any person in any manner nwE 6cl;r,C 7/ff71-1- F&222 /9V C ' so as to become subject to the Workers Compensation Laws M IL 7L/ 3 R&4 RD s'liftf 3 OCCUPANCY GROUP W Dwwae Date Applicant A 1 NOTICE TO APPLICANT If after making this Certificate of v Y1/�(L/V1L4T nK.L(7f OV-00fil OCCUPANT LOAD z t 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 USKO GEOLOGY INSPECTION deemed revoked Ell NO Spec KnOWI El LICENSED CONTRACTORS DECLARATION DCCUPANC.us.P¢CnoN Panic Devices ❑ 1 hereby affirm that I am IKsnsed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO OF EXITS 9 (commencing with Section 7000) of Division 3 of the Bum El ness and Professions Code and my license is in full force and PARKING effect SPACES RE D Pw oviocD License Number Lm Class LIMITED TIME USE Contractor Date AT. R.T. ❑ I am exempt from the licensing requirements as 1 am a PROM TO I censed architect or a registered professional engineer SIZE owno OF INSPECTOR a acting in my professional capacity (Section 7051 Bus- EXISTING BLDG .TORIES JIGNAYURE, mess and Professions Code) cnT USE OF BUILDING FINAL APPROVAL Lac or Reg No Date HOMEOWNER BUILDER DECLARATION ONO OF EXISTING BUILDi aS n LOT AND USE I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Busi 8 2 2 7 6 A ness and Professions Code) NO PARKING ❑ roSPACE{ PROvao¢D # * 00 , 88 S S S 8 D O I as owner of the property will do the work and the structure is not intended or offered for sale (Section *d t d a S 7044 Business and Professions Code U oleo use OF BUILDING IR CONSTRUCTION LLNDING AGENCY AAq� 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 ) Lenders Name PROPOSED MAX Oce Lender s Address PERMIT FEE 1 certify that I have read this application and state that the , above information s correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to budding construction TOTAL FEE ' and hereby authorize representatives of this County to enter u the abov<mentioned property for inspectio; purpose SLF REVERSE I OR EXPLANATORY LANGUAGE -- Hal S91 N I�I�N� Signature of Permit[ :a Date ,WORKERS COMPENSATION DECLARATION 76M444 CE 876(280) MISCELLANEOUS APPLICATION I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insure or a certificate of Workers Compensation Insurance or i` a ce lified copy thereof(Sec 3800 Lab C) Policy No Company FOR APPLICANT TO FILL IN eUILO1N0 n Certified copy Is hereby furnished Bu uOlna wooweSS Loewurr ❑ Certified copy Is filed with the county budding Inspection f NEAREST department LOCALITY GROSS ST a�yv Date ApplicantwAREST DISTRICT n ou• TYPE Pwoe Se+�7`- OSS ST C /S 1� SONNY BY CERTIFICATE Or EXEMPTION FROM WORKERS LEGAL r v COMPENSATION INSURANCE DESCRIPT,on Lor NO ,;3 BLOCX w.. .� /e� Ia,.v,wv } no ow ei.OaS _ No " IcucL.l STATE MAJOR SECOND LOCAL a (This section need not be completed If the work involved TRACT Now Or LOT USE zon¢ aP EaIAL CONDITIONS O by the permit u for one hundred doBgrs (SI00) or leas) USE o. CMZ ¢ SIZE OF LOT eR 1ETING BLDG I certify that in the performance of the work for which this O perms[ is Issued, I shell not employ any person ,n any manner OWNER j tY_Jf" U OCCUPANCY GROUP so as to become subject to the Workers' Compensation Laws AIL ��— W ADDRESS , 11 Date Applicant rn NOTICE TO APPLICANT If after making this Certificate of I 7A02 TEL 1 OCCUPANT LOAD z Exemption you should become subject to the Workers A KATION 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 occuvwrvcr IrveP¢cnoN� Panic Devices ❑ 1 hereby affirm that 1 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 Busl ness and Professions Code and my license Is in full force and effect PARXIrvG REG D PRovloeD SPACES License Number LIc Class LIMITED TIME USE Contractor Date D.T. D.TS ❑ I am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer SIZE of No oP INSPECTOR S acting in my professional capacity (Section 7051 Bus- EXISTING BLDG pTOR,Ea SIGNATURE mess and Professions Code) BS¢NT USE OF BUILDING FINAL APPROVAL 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 Bus, 41 a 6 A ness and Professions Code) No PARKING ❑ I as owner of the property will do the work andSPACES PROVIDED'the # Is •'• a structure Is not Intended or offered for sale (Section 7044, Business and Professions Code) PROPOSED uS¢ of BUILDING CONSTRUCTION LENDING AGENCY 16 —B Z 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) Lenders Name PROPOSED MAX Dec Lender s Address PERMIT FEE I certify that I have read this application and state that the ISSUANCE FEE above Information Is correct I agree to comply with all County , ordinances and State laws relating to budding construction TOTAL FEE 25.00 (Pay to City of Temple City) aV hereby authorize representatives of this County to enter on [h above mention d property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P<rmrttee D' D to WORKERS COMPENSATION DFCLARATION 76M444 CE 875 (2 80) MISCELLANEOUS APPLICATION i hereby affirm that 1 have certificate of consent to self inj sure or o certificate of Workers COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISIONrs Compensatioh Insurance or , a certified copy thereof(Sec 3800 Lab C ) Polley No Compan) FOR APPLICANT TO FILL IN BUIDRESSLDIrvG - AD ❑ Certified copy is hereby furnished L, wooee E9 V� LI✓� LOC.LI7r ❑ Certified copy Is filed with the county building inspection ......T ,department LOCALITY CROSS ST Date ApplicantEAaf9T DISTRIeT No enouP TYrE Ro neap BY CROS 9T alaw O� CONST CERTIFICATE OF EXEMPTION FROM WORKERS LCGAL COMPENSATION INSURANCL DESCRIPTION I LOT No Eto.. m�ww "A"Z (sins Lel STATE MAJOR SECOND LOCAL d (This section need not he completed If the work Involved No oP BLDOE by me permlt IS for one hundred dollars (.SIQD) Or less) TRACT NOW ON LOT U8Q ZONG EP CCIAL CO NOITIONB L) USE OF I TI I certifythat in the eizE of LOT ExIErING eLDe �, 0 performance of the work for which this 0 permit Is Issued I shall not employ anv person in any manner WNEW l'— so so as to become subject to the Workers Compensation Laws AIL ^' OCCUPANCY GROUP _� w ADDRESS Y7All PP a Uata Applicant N NOTICE TO APPLICANT If after making this Certificate of uTr NO Z Exemption you should become subject to the Workers L6 O/T —/ OCCUPANT LOAD Compensation provisions of the Labor Code you must forth APPLICATION FOR EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION deemed revoked ❑ ❑ NO Spec Know) ❑ LICENSED CONTRACTORS DECLARATION occurwrvcY iNsrixcrloN Panic Devices ❑ 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO OP EXITS 9 (commencing with Section 7000) of Drsision 3 of the Busl ness and Professions Code and my license Is In full force and effect PARKING A SPACES REO D D PROVIDE. rrL��i__cense Number LIc Class — LIMITED TIME USE pntractor Date I AT. AT. 1❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OFO or INSPECTOR S N acting in my professional capacity (Section 7051 Bus EXISTING BLDG :TOROSE SIGNATURE (ness and Professions Code) QeENr uee OF eulLOlrvG FINAL APPROVAL Oz Loc or Keg No Date ! fD Q r G I I NO OF EX.STI.Q QUILDINGB • • • HOME OWNER BUILDER DECLARATION ON LOT AND use 1 hereby affirm that 1 am exempt from the Contractors 0105-8 J License Law for the following reason (Section 7031 5 Bust ness and Professions Code) NO PARKING SPA 95 PROVIDED ❑ 1, 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) PWI5POSED DEE OF BUILDING _ CONSTRUCTION LENDING AGLNCY C ' 1 hereby affirm that there Is a construction lending agency A 'oFaif" AJ for the performance of the work for shish this permit Is issued(Sec 3097 Civ C) Lender s Name i PROPOSED MAX OCC Lender s Address PERMIT FEE ' I certify that 1 have read this application and state that the above information rs 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 Counts to enter upon t// pro//pJJerty (L� the above mentioned for inspection purposesSEF REVLRSL 1 OR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATIONDECLARATION 76M444 MISCELLANEOUS APPLICATION CE 875 (11 84) insure hereby a�certificirm ate of Workert I have a s'Compensation Inertificate of suurancce self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ' a certif'ted'copy thereof(Sec 3800,Lab C) C"' Policy No Company FOR APPLICANT TO FILL IN aulLol95 w DORaES V FiCertified copy Is hereby furnished BUILDING LOCALITY. wDDRESs ❑ Cert�ed copy is tiled with the county building inspectso 905 TeMYLE GTT 6L (1 N¢AR¢CT LOCALITY department caoeS Sr � v Date Applicant NaARHer I ` MCT No GROUP Tyre oc¢e ¢y.eY Crt088 8T WU ZU S CONIY `J CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I LOT NO BLOCK MOP !co^OwL�. STATE MAJD SKCOND LOCAL /7t NO OF SLOGS\Susi sperm Seed not be completed If the work or less) TRACT NOW ON LOT Uy¢ zONE SPECIAL CONDITIONS by the permit to for one hundred doBers (5100) or less) ILS¢ of --.0 /I SIZE OF LOT ¢x%TINO ISLD0 1 J I artdy that to the performance of the work for which this I (Ol�� permit u issued, I shall not employ any person in any manner tj so as to become subject to the Workers' Compensation Laws MAILER OCCUPANCY GROUP ADD.a's Daft Applicant v.+ NOTICE TO APPLICANT [f, after making this Certificate of' clTr li TOL ?$6— OCCUPANT LOAD o_ Exemption, you should become subject to the Workers' Compensation provinoms of the Labor Code, you must forth APPLIC TION FOR EXIT HARDWARE with Comply with such provtsions or this permit shall be TRAILER UEC: ❑ GEOLOGYdeemed revoked IN¢PH cr1oN No Spec Knowl ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI (LIST ITEMS SLOW) 9 (commencing with Section 7000) of Division 3 of the Busy NO of EXITS ness and Professions Code,and my license is in full force and effect J)NW OF PARKING SPACES R8q D D FROVIDiO (� License Number Lic Class 'ETC ��2. Contractor Date &M r Cr LIMITED TIME USE DAT• SATE PROM I am exempt from the licensing requirements as I am a To licensed architect or a registered professional engineer else OF NO OF INCPE Crow S acting in my professional capacity (Section 7051, Bus- %ISTING BLDG STORIES SIGNATURE mese and Professions Code) D �'CC FINAL APPROVAL (- (y Lic or Reg No Date PRKSKNr USE OF BUILDING / V HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDING oN LOT AND UBE N0 r I hereby affirm that I am exempt From the Contractor's _ lJJ G License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) No PARKING /� SPACES PROVIDED I I OOpO-0001 10/ �7 V9 1, as owner of the property, will do the work and the I structure Is not intended or offered for sale (Section I r N' (,�' 6072 1 AM 9;,44 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROP.CED USE OF BUILo 1NG I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is O f a 1 1 Issued(See 3097,Civ C) Lender s Name PROPOSED MAX OCC \ \ Lender's Address I certify that 1 have read this application and sinPERMIT FEE e that the , above information is correct 1 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 the above-mentioned property for inspection purposes \ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date HORKLRS COMPENSATION DECLARATION 78M444- 1_� CE 875(1184) MISCELLANEOUS APPLICATION I hereby.tient that 1 have a certificate df convent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Worker s'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN .u1LOIno woow[SS I�.pw E, _ C I� Certified copy is hereby furnished RX .Bnow ILOstn:U .. 4 2 OS Te fN LOCALITY Certified copy I filed with the county budding inspection LOCALITY NEww[ST department XX ewoLO rnCA Sik Date Applicant 2 LA O _� NewCoeA.e ESrSr LJ412 ler No .our TTP- c[eSED Er 18. cDNS r CERTII KATE OF EXEMPTION FROM WORKERS' LEGAL eI COMPENSATION INSURANCE DESCRIPTION Lor.o BLOC. Mo• ;cw^��� .TATE wwiow e[cono LOCAL LD6a (This section need not 6e Completed if the work involved TRACT Or B ed rwwcr rvor on Lor uS[ :onE Sr[e.wt eono.rwNS by the permit is for one hundred dollars ($I00) or less.) USE or [...TING SLOG 1 certify that m e.zE or Lor the performance of the work for which this o permit Is issued, 1 shall not employ any person in any mane Gw.a. of buildin S so a1 to become subject to the Workers' Compensation Laws MAIL wD....S I OCCUPANCY GROUP B-a Date Applicant AM NOTICE TO APPLICANT If, after making this Certificate of elrr 12ad2a .Bice t ( OCCUPANT LOAD z Exemption, you should become subject to the Workers' — Compensation provisions of the Labor Code,you must forth APPLICATION FOR EXIT HARDWARE F with comply with such provisions or this permit shall be TRAILER US[ n[OLOGr INSPECTION 0 No Spec Knowl Ii 1 �� deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANcr INSPECTION ❑ Panic Devices _ •I_,_Ifif11 - - '.e I hereby affirm that I am licensed under provisions of Chapter Swr[Tr PERMIT (tiITEMS[Ma auoi) 9 (commennrlg with Section 7000) of Division 3 of the Busy NO Or EXITS� Tress and Professions Code,and my license is in full force an effect I Name of business PARKING SPACES .too � rwov mco License Number Lie Class i' LIMITED TIME USE Contractor Date DATA RATS El1 am exempt from the licensing requirements as I am a •.o. TD licensed architect or a registered professional engineer SIZE or No or INSPECTOR S acting in my professional capacity (Section 7051, Bus- FASTING BLOC SroPIES uG URE mess and Professions Code) PRESENT USE or BUILDING FINAL APPROVAL r� ` Lie or Reg No Date HOME OWNER-BUILDER DECLARATION no or SX STING BUILDINGS O �� ow Lor AND tie[ I hereby affirm that 1 am exempt from the Contractor's t� License Law for the following reason (Section 7031 5, Busr ness and Professions Code) NO PARING 1, as owner of the property, will do the work and the SPACE. PROV.O[O structure is not intended or offered for sale (Section f 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY Pw OPO[EO USE or BUILDING I Hereby affum 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 I certify that 1 have read this application and stale that the PERMIT FEE above Information is correct I agree to comply with all County ISSUANCE FEE ordinances and State taws relating to building construction, 1 and hereby authorize representatives of this County to enter TOTAL FEE 25.001 upon the above-mentioned property for inspection purposes 1 8£E REVERSE FOR EXPLANATORY LANGUAGE XX g 6 / , xx 02-22 - 9S Si patiof Pernuttc Drte WIJKACKJ LVMFLI`IDAIIVry UtILAKAIIVry >a1 2000sOPW11 .„� MISGtLLAMtVVS iarr�.I�.HI �LJIY I h �alT rte that 1 have certificate of consent self COUNTY OF LOS ANGELES WILDING AND SAFETY DIVISION msdfe.or a certificate of Workers Compensation Insurance or a certified copy thereof (Sec 3800 Lab C) Policy No. _ Company __ FOR APPLICANT TO FILL N. euILOINc Gtr H BUIL Ol �1DBE3$ `j ADDRESS D �J tet_ "L� Certified copy Is hereby furnished Certified copy ns I Iled with the county building inspeLtion CITY/ ZIP LOCALITY �- departmentL / NGRLST CROSS ST Dalt Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT DiaTR �NOf 2rP TYPE CESSED BY OV 4 CERTIFICATE OF EXEMPTION FROM WORKERS CD ST TRACT BLOCK LOT No _ COMPENSATION INSURANCE vA (This Section need not be completed If the wort( Involved ASSESSOR MAP BOOK PAGE PARCEL w 1 iCO'4ei STATE MAJOR SECOND LOCAL by the per ul 1$ for ogle hundred dollars (5100) Or ICsS) W, UMEZOVE SPECIAL CONDITIONS I certify that in the performanLe of the work for which this i OWNER ` TEL NO permit is Issued, I shall not employ any person In any manner Pro eit j,(a S1Sjp SO as to become subject to the Workers Compensation Laws I ADDRESS Z 6 t% T OCCUPANCY GROUP Date Applicant CITY gg Zip NOTICE TO APPLICANT If after making this Certdicate Lt SCt R Y C C% of Exemption you should become subject to the Workers OCCUPANT LOAD Compensation provisions of the Labor Code you most forthwith APPLICATION FOR E OT HARDWARE comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ revoked No Spec Known LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter SAIETY PERMIT❑ (LIST IT[Ma BELOWi 9(commencing with Section 7000)of Dn Ision 3 of the Business NO OF EXITS and Professions Code and my licen.e is In full force and effect /I'LL )2 C,-, License Number LIL Classr �f� SPACES RED D PROVIDED -C LSC JLcC J 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 professwnal capacit (Section 7051 Business SIZE of ND of INSPECTOR a and Professions Code) exlsrlNC BLDG STORIES SIGNATURE Lic or Reg No Date PRESENT Use OF BUILDING FINAL APPROVAL7,7 /C,cfj C b O �1 HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE I ' I hereby affirm that I am exempt from the s License Lar for the following reason (Slltion 7031031 5 5 Business and 0 ' Professions Code) No PARKING �SPACES PROVIDED I as owner of the propert} well do the work and thq� structure is not Intended or offered for sale(Section 74X -ROPOSED USE OF BUILDING Business and Professions Code) 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 (See 3097 Civ C) PROPOSED MAX OCG Lenders Name APPLICANT(R T) TEL NO Lender s Address ADOREae I certify that 1 have read this application and state that the above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to budding construction and hereby authorize representatives of this County to enter upon a FEE the above-mentioned property for inspection purposes Q -DTAL IEE �7 i t - D SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date 110RAI ILS (OAIPI NS.\IION UI( LARAfION CE 876 111 841 MISCELLANEOUS APPLICATION J'1 CE 876 L, I ".retry affnm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION IILJII mare or a certificate of Workers (ompenallon Insurance,or I certified copy thereof ISeL 3800 Lab C) PNh(y No _ — (ompnny — FOR APPLICANT TO FILL IN BO ILOIN6 ���� woowus FICertiflLd Lop) Is hereby furnished culLn m° Lou urn / XX woowEs• ElCertlDed wpy is bled%%tlh the county budding Inspection LOCALITY NEAREST department 31;$ ew Dff ST ])ale Appinant—_ eneAe•T DISTRICT No ;Fop IT cEfuD Br ewofs ST G Q eoNfry� (I R I II I(All 01 EXEMPTION 1 ROM WORKERS LEGAL 1� (ONIPI NSA nON INSURAN(1 DESCRIPTION LOT NO BLOCK MAP ...NA• ICIn<Lll STATE MwlOw •{GONG LOCAL NO OF BLOBS (Flit, section need not be completed if the work Involved TRACT nee ON LOT USK :owe •PEcuL Co wo monS by lite permit Is for one hundred dollars (11100) or less) use or SIZE OF LOT BXIfTING eLo I LertifyI tint d, the performanLC employ of the work for any ichma this pcnnu n Ica"ed, I shill not employ any person In any rrunneRX ow New of building 1 v. is to hctome sulgrU to the Rotker% (ompenution I Tus OCCUPANCY GROUP °i wwu woowe•s Date — __ ApphL Int NOIR I 10 APPLK ANI If after nuking this Certificate of CITY NO I. OCCUPANT LOAD >> I xemption, )ou should become subject to the Workers APPLICATION FOR EXIT HARDWARE (ompenation ptovwons of the labor Code you must fork O with Lompl) Ruh mit prO%t%anns or tilts permit shall be TRAILER USE ❑ OeOLOOV INSPECTION ❑ filo Spec KnoWl deemed te%oked I R 1 NSI 1)(ON 1 RACIORS DECLARATION OCCUPANCY INSrecTlon 11Panic Devices I herch) affirm Ihil 1 am licensed under provisionsof luipler SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (anemenLing with Section 7000) of Dwisson 3 of the Bun- wo o. EXITS nes% and Professtona(ode and m) licence Is in full fora anix Name of business effeLt n PAwNIND weo o --tit- V S, KS I at.nsL Number I IL (lass LIMITED TIME USE l onfr U Nr _ _ —__ _ — Date _— 0 DATE ^"'• El1 Tm exempt from the licensing requtremenls as 1 am a I tensed anhlle" or a registered professional engineer SIZE or NO OF I:SPEW oR 2d Ing to my professional Lapactty (Section 7051 Bus EXISTING BLDG STORIES messand Profe%slons(ode) FINAL APPROVAL PRESENT use e1 BurLOrn6 1� 10 1 "c nr RLg No - _ _ _ _ ---- Dale /,{ �(� IIONII OWN[ R 131111 DFR DI CLARAIION No of EXISTING BUILDINGS (%e ON Lor Ano ufe (' �'JF MCI I heteb) nftunl that I Ito exempt from the Contractors 1 ILenw I aw for Ilse lollN%%Ing retain (Seddon 7031 5 Bus, nes% and Professions(Niel No PARKING I, a% owner of (lierN eel will do the work and the SPACef PROVIDED structure not upended or offered for sale (Section ¢i� (�pll t 1 a tr 7044 Rusme%s and Professions(ode) (ONS I RLICI ION I LNDING AGLNCY PROPOSED USE or Bull-DING I hereb% affirm that thtre is T Construction lending agency bc NUTSge for the perfonnmLC of the work for whlLh this permit Is Issued(Sec 3097 (w ( I I ender s Name PRDPOSeD MAi-OCC I Coit."s Addtc<s___ _ __ _— —_ — i I certify Ilut I hnr rt.ad 1111% dpphL loon coif state Ilial the PERMIT FE! IbO%L InfNrlll"tion I%Lorrc0 I "Fret. In Lomp1) wllli all(Ounty ISSUANCE FEE ordinance% Ind Stale tau% rLlating to building construdion, ' and hereby aulhorve representatwes of this County to enter TOTAL FEE 25.00 upon the i1Xne mentioned property for mspLLtion purpose% / SFF REVERSE FOR EXPLANATORY LANGUAGE XX XX / XAW I h n.