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HomeMy Public PortalAbout5801-5803-5805 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION 20-0063DPW12/90 f I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION inguie or a certificate of Workers'Compensation (nsurancc,or l a certified copy thereof(Sec. 3800, Lab.C.) Policy Na Company—_____ __ FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUIL N A R LOCALITY Certified copy is filed with the county building inspection �� zl O department. NEAREST GROSS ST. Date Applicant — SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRI DISTRICT . GRqup TYPE P SE BY CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LAT NO. A CONST. COMPENSATION INSURANCE MAP HIGHWAY NO. ICIRCLEI STATE MAJOR SECOND LOCAL (This section need not be completed if the Work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS I' by the permit is for one hundred dollars ($100) or less.) 1 1 certify that in the performance of the work for which tIt[ R R TEL No. ids I I permit is issued, I shall not employ any person in any manner t so as to become subject to the Workers' Compensation Laws.x ADDRESS OCCUPANCY GROUP t' Date Applicant _— _�i qWY ZIP NOTICE TO APPLICANT: If, after making this Certificate 7 A OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ revoked. No Spec.Know[. ❑❑ OCCUPANCY INSPECTION❑ Panic Devices LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ ILIST ITEMS BELO 9(commencing with S tion 70 0)of Division 3 of the Business NO.OF EXITS and Professions Code, nd my nse is in full force and effect. syr PARKING• REQ•D == PROVIDED License NuD-1— ic.Class _ __ SPACES Contractor ate —__ ___ _ _ LIMITED TIME USE DATE DATE Nd t rom the licensing requirements as 1 am a FROM: TO: tett or a registered professional engineer rofessional capacity(Section 7051.Business SIZE OF NO.OF INSPOns Code). EXISTING BLDG. STORIES RE Lia or Reg. No. Date PRESENT USE OF BUILDING FINAL APPROVAL U u. HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS -W-16 ON LOT AND USE I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): NO.PARKING � El I. as owner of the property, will do the work and th SPACES PROVIDED structure is not intended or offered for sale(Section 7044, PROPOSED SE OF BUILDING Business and Professions Code). CONSTRUCTION LENDING AGENCY SLI G I hereby affirm that there is a construction lending agency for C F— the performance of the work for which this permit is issued I (Sea 3097,Civ.Q. PROPOSED MAX.OCC. Lender's Name *PPLICANT(t1RINTI Y ! TEL O._� Lender's Address ADDS SS K , I certify that I have read this application and state that the cfz�w AlIvrl c= above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes. 1 TOTAL FEE /4 o� 0U i SEE REVERSE FOR EXPLANATORY LANGUAGE g�Sig�nat.,. f Permit ee Efate I I ' ..ORKERS'(,'UMFhNSAl1UN 1A1k LAKAIIUN I 20-OOB30PW72/90 l(�j 4j""rLrL,Hj1IG��..►4.J� E•111—lrll_.lt�tit •a�.l�1l I hereby'affirm that I have a certificate bf consent to self COUNTY OF LQ3 ANGELES BUILDING AND SAFETY DIVISION I.djnsureY or a certifieate of,W&Imrs'Compensation Insurance,or ;;•,. w •a Certified copy thereof (Set:3800,Lab.C.): pOEcyr'Na _ Company FOR APPLICANT TO FILL IN BUILDING ". .- BUILDING ADDRESS ADDRESS , I ❑ Certified copy.is hereby;furnished g O -TEt­�-QCF_ C1—I; •'SC u , LOCALITY ' ❑ Certified copy is filed with the county building inspection CITY ZIP NEAREST, I depat'tmfent. 1�w,eQ. Cg Com' I � g C) CROSS ST. Date +' Applicant SIZE OF LOT NO.OF.BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY • CONST. O CERTIFIC&E OF•EXEMPTION FROM WORKERS' I TRACT 'BLOCK LOT NO. r4"P (CSRCL"r COMPENSATION INSURANCE V y0: IeIRCLBI STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USEZONE SPECIAL CONDITIONS RIG by the permit is for one hundred 4ollars ($100) or less.) .s+pggr er TEL NO, L certlfy'that in the performapce.of the work for which this. n+. S� 1oa6• f 3 permit is issued:I-Shall not employ'kny person in any manner ADDRESS C. so as to become subject to the Workers' Compensation Laws. 1K=.& e h_ OCCUPANCY GROUP Z Date Applicant . I CITY zIP NOTICE TO APPLICANT. If.' after making this Certificate %. OCCUPANT LOAD of Exemption. you•should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the-Labor Code.you must forthwith comply with Such provisions Or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ revoked. i OCCUPANCY INSPECTION Panic Devices ❑ LICENSED 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 Business' . . •ame O tls!Eess "'❑ and Professions Code•and my license is in.full force and effect. • PARKING• REQ'O O PROVIDED D License Number Lia Class SPACES I Contractor Date LIMITED TIME USE i DATE DATE El am'exempt from the licensing requirements as I am al , , FROM: TO. licensed'architect or a'registered professional engineer acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S and Professions Code). EXISTING BLDG. STORIES SIGNATURE. I PRESENT USE OF BUILDING FINALAPPROVAL Lic.or Reg.Na - Date HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS 1 ON LOT AND USE , I hereby affirm that I am'exempt from the Contractor's License Law for the following reason (Section 7031.5• Business and Professions Code): No.PARKING .SPACES PROVIDED , i El I, as owner.of the property, will do the work and the,I structure is ndt intended or offered for sale(Section 7044,)l PROPOSED USE OF BUILDING Business and Professions Code). �C) S P, O i CONSTRUCTION LENDING AGENCY _ Thereby affirm that there is a construction lending agency ford the performance of the work for which this permit is issued ' (Sea 3097,Civ.Q. PROPOSED MAX.OCC. 'Lender's Name I• APPLICANT(FRIT) TEL NO. •- Z �.'va. J`'V t7k_ . Lender's Address ADDRESS I certify that I have read this application and state that the' REo�owll, ALV IaQT_ �6g above information.is correct I agree to comply with all County PERMIT FEE ordinances and State laws relating'to building construction,and hereby authorize'representatives.of this County to enter upon ISSUANCE FEE i the above-mentioned property for inspection purposes. •• --• �`' TOTAL FEE g SEE REVERSE.FOR EXPLANATORY LANGUAGE Signature of Permittee Date t I ! WORKERS'COMPENSATION DECLARATION I 200063DP. /90 MISCELLANEOUS' APPLICATION - ry I hereby affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING•AND SAFETY DIVISION 'inure,or a certificate of.Wdrlcers'Compensation Insurance,or ,y: a certi.•fied copy thereof(get;.3800, Lab.C.)• ' t Policy'No. Company FOR APPLICANT TO FILL.IN BUILDING i BUILDING AODR� r 1 ADDRESS I, ❑ Certified copy.is hereby;furnished g �^ff p� /Cir+^ ly�, LOCALITY { I ❑ Certified copy is filed with the county building inspection CITYzIP C, NEAREST I department e/rr G/, 7V — CROSS ST. Date '' ` ' Applicant SIZE O LOT NO.OF SLOGS.NOWONLOT DISTRICT NO. GROUP TYPE PROCESSED BY a CERTIFICATE OF EXEMPTION FROM WORKERS' �/ CONST. ( I TRACT BLOCK LOT NO COMPENSATION INSURANCE . MAP HIGHWAY V NO. (CIRCLE) STATE MAJOR SECOND LOCAL. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS 9Z by the permit is for one hundred dollars ($100) or less.) C ( I.certify that in the performance.of the work for which thisy er TEL No. permit is issued:1 shall not employ any person in any manner n. so as to become subject to the Workers' Compensation Laws ADOREss� U I o OCCUPANCY GROUP tn ( I Date Applicant . CITY /,, zip `�, C� NOTICE TO APPLICANT: If. after making this Certificate `te�`^� � a v OCCUPANT LOAD of Exemption. you should become subject to the Workers' APPLICATION FOR Compensation provisions of the-labor Code,you must forthwith EXIT HARDWARE: comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ ' revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[% Panic Devices ❑ 1 I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) { F 9(commencing with Section 7000)of Division 3 of the Business ame O u8 eSs NO.OF EXITS and Professions Code•and my license is in full force and effect. PARKING- REWD O PROVIDED O License Number Lic.Classn.,n� U SPACES [ I I Contractor Date 5c LIMITED TIME USE DATE DATE I am exempt from the licensing requirements as I am a El To: FROM: ' licensed architect or a registered professional engineer { acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S S 1 ` I and PfOfeSS10RS Code). EXISTING BLDG. TORIES SIGNATURE. Lic or Reg No Date PRESENT USE OF BUILDING IFINAL APPROVAL -/9 Z ' HOME OWNER-BUILDER DECLARATION NO.OFEXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ( ' I Professions Code): NO.PARKING SPACES PROVIDED i ❑ I• as owner of the property, will do the work and the structure is not intended or offered for sale(Section 7044,11 PROPOSED USE OF BUILDING Business and Professions Code). { I CONSTRUCTION LENDING AGENCY iI hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ' ( I (Sec. 3097,Civ.Q. PROPOSED MAX.OCC. j Lender's Name A—P� ICA NT r (q b ) /eA / TEL�O. 0 y Lender's Address A DR S ! I I certify that I have read this application and state that the I�� ti. /10 Zboy above information is correct I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize representatives.of this County to enter upon ISSUANCE FEE t7y,l the ab a property for inspection purposes - " S 1 TOTAL FEE % SEE REVERSE FOR EXPLANATORY LANGUAGE ignature Permittee Date WORKERS'COMPENSATION DECLARATION CE B75(71.84) M ISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or ► COUNTY OF LOS ANtEL'ES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec.3800,Lab.C.). Policy No.--__Company FOR APPLICANT TO FILL IN BUILDING r Cj% � n ADDRESS C.erllflC(1 Copy IS IICICi)y CUInISIled. X BUILNG- ff ..v 3 LOCALITY Ap5 ❑ Certified copy is filed with the county building inspection L-OCA LITYjI� �!. ����h NEAREST department. 1]li - r (�' I-e I V cENa 9r. Date __Applicant ___ NEAREST DISTRICT NO; GROUP CONST. PROCESSED BY CROSS ST. CITY C'ERT'IFICATE OF EXEMPTION FROM WORKERS' F LEGAL C'OAIPENSATION INSURANCE DESCRIPTION TLoTma. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO.OF BLOCS. NO. (CIRCLE) (This -section need not be completed if (lie work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one Hundred dollars ($100) or less.) USE DF SIZE OF LOT .� EXISTING BLDG. 1 certify that in the performance of the work for which this,,- permit his J permit is issued, I shall fiat employ any person in any manned o`ER p.f htid111 •® De SII as to became subject to Workers 'n pensation Laws. MAIL /f/� j A Q.�, -y ,��j OCCUPANCY GROUP c� ADDRESS o-/0 E. LA:3 �lV.A• �.� ✓!` V Applican 4I NOTICE TO APPLICANT: If,after making this Certificate of CITY-SAA _ NO. OCCUPANT LOAD N Exemption, you should become subject to the Workers r 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 ❑ 1.1('1:NSE•:D CONTRACTORS DECLARATION I hereby affirin that I am licensed under provisions oCChapter 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 arijk' ~ �---�- effect. M1_Name -Gf bu-� $•S v PAIIKING REQ'D PROVIDED 1 1 SPACES 11 ....JJ Licensc Nunibcr-_ Lic.Class � LIMITED TIME USE Contra Ctar _.___._.-____--_-Date_ _- DATE DATE ' FROM. TOC ElI airs exempt fromthe licensing requirements as I am a CTO licensed architect or a registered professional engineer SIZE OF NO.OF IN sg NATUR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). FINAL APPROVAL ' PRESENT USE OR BUILDING Lic.or Reg.Na._ .______.— _Date 17 l 1 - II()Afl:OWNER-BUILDER DECLARATION I NO. OF EXISTING BUILDINGS L'I � C ON LOT AND USE I I Hereby affirin that I am exempt from the Contractor's �: i1 d/ItG G�1j�lf�.��,(itlj License Law for the following reason (Section 7031.5. Busi- ness and Professions Code): NO. PARKING F11, 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). CONST'RUCHON LENDING AGENCY PROPOSED USE OF BUILDING I Hereby affirin 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 MAA-OCC. Lender's Address.---•-.-.---__-._-- — ' 95.0 1 certify that i have read this application and slate that the PERMIT FEE above infuriation is correct. I agree to conipiy with all County I ISSUANCE FEE ordinances and State laws relating to building construction, and Hereby authorize representatives of this County to enter TOTAL FEE 25.00 u a the above- elr med�firclaerty for inspection purposes. 1 ` /_�� XX SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION . 76M4" I CEE875(11-84) MISCELLANEOUS APPLICATION �j I hereby affirm that I have a certificate of consent to self' COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION IuI m:.=-% or a certificate of Workers'Compensation insurance,or a certified copy thereof(Sea 3800,Lab.Q. � L_I Policy.No.—Company FOR APPLICANT TO FILL-IN i/U iLDEING /tU DRSS Certified copy is hereby furnished. BUILDING ADDRESS LOCALITY or ❑-Certified copy is filed with the county building inspection LOCALITY •I AEAREST em l Te Cit (:ROSS ST. department. P OISTRICT NO. GRO P TYPE P SSED BY Date Applicant NEAREST l� CROSS ST.. (% CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' ! LEGAL a 1 COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL "`1tlND. (CIRCLe) . . (This section need not be completed if the work involved' TRACT NONOW OF BLDGS ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the ork for which this permit is issued,I shall not employ any son in any manner i OWNER G� G,jo�( '_ so as to become subject to the Workers' oDpenation Laws., MAIL c OCCUPANCY GROUP ADDRESS ` y 1 Date Applicant NOTICE TO APPLICAA'T: If,after making this Certificate of CITY ,� ,/� G�. NO. a ' OCCUPANT LOAD Exemption, you should become subject to the Workers'I 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. i LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONS Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS SELOY.'� I 9 (commencing with Section 7000) of Division 3 of the Busi-j — No. OF EXITS � I ness and Professions Code.and my license is in full force and effect. IRKING R&Q,O D PROVIDED SP,A S ll��J License Number Lic. Class I LIMITED TIME USE f Date f;-..Z.. Contractor DATE FRIM: � TO:-1 1 am exempt from the licensing -equirements as I am 1'licensed architect or a rezigered professional enggineer OF INO. OFISIDE ATUREacting in m}- professional capacit} SecTion '051. Bus- sTING SLOG. STORIES 1 inessand Professions Codel. FINAL APPROVAL I �.. �.� I PRESENT USE OF BUILDING Lic.or Reg.No. ." Date 1-e I I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS I ON LOT AND USE I hereby affirm that I am exempt from the Contractors,, � �11/L A _U.-InAt}E- 4.`,'4 i License Law for the following reason (Section '031.5. Busi-' nese and Professions Code): NO. PARKING 1, as owner of the property. will do the work and the'( SPACES PROVIDED structure is not intended or offered for sale (Section' 7044,Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency, t for the performance of the work for which this permit is' issued(Sec.3097,Civ.C.). l Lender's Name PROPOSED MAX. OCC. Lender's Address ! I PERMIT FEE 25.00 I certify that I have read this application and state that the i above information is correct.1 agree to comply with all County ISSUANCE FEE ordfnanc d State laws relating to building construction. t �l and here y uthorize representatives of this County to enter] TOTAL FEE 25.00 upon the b do ied property for inspection p rposes. I e n ,SEE REVERSE FOR EXPLANATORY LANGUAGECJ !�j Ir, ignat 'e of isermittee Date WORKERS'COMPENSATION DECLARATIONCE 8754(11-84) MISCELLANEOUS APPLICATION 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.). �-'-fy Policy No. Company -+ r 190ILDING FOR APPLICANT TO FILL IN ptiORES. FlCertified copy is hereby furnished. BUILDINGa 11q LOCALITY ADDRESS ❑ Certified copy is filed with the county building inspectionLOCALITY / NEAREST department. 1. Cr OSS ST. . Date Applicant NEAREST DIISTRICT No. I GROUP ITYPE PROCESSED BY CROSS ST. �D' O CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY A ND. HIGHW(CIRCY 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 LOT EXISTING BLDG. /1 IR o permit is issued,I shall not employ any person in any manner OWNER QF igv%/ j� UliE (7 k so as to become subject to the Workers' Compensation Laws. MAIL //'1L)n �, �R„� r,, . OCCUPANCY GROUP �a o ADDRESS {•�IJTr✓ ilio WAS ~' Date Applicant Q LLIJ NOTICE TO APPLICANT: If, after making this Certificate of CITY n NO 1� _� 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. 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/J effect. 19 (J`�^2 PARKING REQ'D PROVID EO SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ❑ 1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF FROM: To: INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). �•' PRESENT USE OF BUILDING IFINAL APPROVAL Lic.or Reg.No. Date & HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE l �} I hereby affirm that I am exempt from the Contractor's � 7/231/93 License Law for the following reason (Section 7031.5, Busi- 1'13(=1'1—( (3(31 ness and Professions Code): NO. PARKING J, 10977 j AM 9-015 1, as owner of the property, will do the work and the SPACES PROVIDED y�r/ structure is not intended or offered for sale (Section 1' 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 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 upo lte above-m tone woperty for' spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date