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Home My Public Portal About5818-5818 1/2 TEMPLE CITY BLVD_Miscellaneous__ i WORKERS'COMPENSATION DECLARATION I CE 875(11-84) M I SC E L LA N EO US 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. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. Bu1LDING'1 y LOCALITY ADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST department. 1� r"� C/�'' c 'ju CROSS ST. Date Applicant I NEAREST 'DIST$$1FiCT yyyQQQ yyyjjjttiOUP TYPE ESSED BY CROSS ST. `j n�' ie CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL d v COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. OF BLDGS. No, (CIRCLE) (This section need not be completed if the work involved S 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. O}.. I certify that in the performance of the work for which this I e permit is issued,I shall not employ any person.in any manner so as to become subject to the Workers' Compensation Laws. I MAIL I OCCUPANCY GROUP o ADD Date - Applicant RESS Lu NOTICE TO APPLICANT: If,after making this Certificate of I CITY No. r'OCCUPANT LOAD y Exemption, •you should become subject to the Workers' I z Compensation provisions of the Labor Code,you must-forth- 1 APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall beI TRAILER USE ❑ GEOLOGY INSPECTION ElNo Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION I OCCUPANCY INSPECTION❑ Panic Devices I hereby,affirm that I am licensed under provisions of Chapter I 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 1�-J � ) License Number Lie. Class I LIMITED TIME USE Contractor Date I DATE DATE I am exempt from the licensing requirements as I am a : licensed architect or a registered professional engineer SIZE OF NO,OF ' PROM: To: INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). I � PRESENT USE OF BUILN DIG �- FINAL APPROVAL (� Lie.or Reg.No. Date HOME OWNER-BUILDER.DECLARATION I No. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm.that I am exempt from the Contractor's ; Ii)�l� _Iljjl t 4/ 15/11 License Law.for the following reason (Section 7031.5, Busi-El 7 ness and Professions Code): NO. PARKING ;(, Ali Oro 1 f I, as owner of the property, will do the work and the SPACES PROVIDED v 296 structure is not intended or offered for sale (Section I 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED use of BUILDINGY. �' 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 � Kb I 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 1 r ordinances and State laws relating to building construction,( and hereby authorize representatives of this County to enterTTA OL FEE pa upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I + Sig ture of P ttee 7 Dat j I WORKERS'COMPENSATION DECLARATION CE 875 M I SC E L LA N P O JS APPLICATION �I CE 875(17-84) I hereby aiffirm that I have a certificate of consent to self i � +� insure, ora;certificate of workers'Compensation Insurance,or COUNTY OF LOS ANGELES ,BUILDING AND SAFETY DIVISION a certified copy thereof(Sec.3800,Lab.Q. A Policy No._,--CompanyFOR APPLICANT TO FILL IN BUILDING AdDR ESS Certified copy is hereby furnished. vILDING — ADDRESS 5818 N.TEMPLE CITY BLVD LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. t Date Applicant 1 NEAREST DISTRICT NO. GROUP TYPE P CESSED BY CROSS ST. I CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE } DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. NO. OF BLDGS. (CIRCLE) (This section need not be completed if the work involved I TRACT NOW ON LOT WITT, AL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING B DG. d 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 G�� y so as to become subject to the Workers' Compensation Laws. MAIL �j/� OCCUPANCY GROUP //}� o Date Applicant W LU NOTICE TO APPLICANT: If,after making this Certificate of CITY 9T O OCCUPANT LOAD °- N 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 ElI 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 Busl- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. " PARKING REQ'D PROVIDED SPACES License Number Lic.Class 1 • 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.OP INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES I SIGNATURE inessand Professions Code). FINAL APPROVAL Z PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE V 't 1 I hereby affirm that I am exempt from the Contractor's �D 31 l`l00-0001 9/14194 License Law for the following reason (Section 7031.5, Busi- I 6900 1 P !I '4 Q 3L� ness and Professions Code): NO. PARKING ❑ I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). 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 i 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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Permittee Date µJRKERS'COMPENSATION DECLARATION CE 9751(2 a0l M I SC E L LA N E O U S APPLICATION CE A75 I hereby affirm that I have certificate of consent tself COUNTY OF LOS ANGELES :I BUILDING AND SAFETY DIVISION insure,or a certificate of Workers' rs'Compensation Insurance, e,or , a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANTTO FILL IN BUILDINGDDRESS t e •❑ Certified copy is hereby furnished. uILDIN� / J �"' /%r��' C J'- LOCALITY DRESS C. V' ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PRO SSED BY CROSS ST. '��`� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �/1 ~ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY' NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved NO. OF SLOGS. USE ZONE SPECIAL CONDITIONS 0 P TRACT NOW ON LOT O by the permit is for one hundred dollars ($100) or less.) V USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this 0,. X permit is issued; I shall not employ any person in any manner I WNER Q so as to become subject to the Workers' Compensation Laws. I AIL �� ypt a n OCCUPANCY GROUP LU Date Applicant DOREss � N 76_ , Cj Qf OL a U)TEL. NOTICE TO APP.LICANT:•If, after making this Certificate of CITY NO. :ZS —7d3 OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLI ATION 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 C] No Spec. KnOWi. El ' �u LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hefeby 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 ;Pa RKING effe�t. REQ'D O PROVIDED D ' SPACES License Number Lic.Class . � LIMITED TIME USE- Contractor Date DATE DATE ❑ FROM: TO: I am exempt from the licensing requirements as I am it licensed architect or a registered professional engineer SIZE OF NO. OF INSPE GTO R'S acting in my professional Capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE ' iness and Professions Code). I RESENT USE OF BUILDING FINAL APPROVAL Lic,or Reg.No. Date I HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS 1 ON LOT ANO USE i • 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 CS2J �j ALJ g ❑ 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). I PROPOSED USE OF BUILDING 79-2,�' CONSTRUCTION LENDING AGENCY 1 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 on the ab a-me, tfoned pro rt for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permitta Date WORKERS''COMPENSATION DECLARATION I76M444 I� I S C E ll R ,ii ga p fi°®II II fi ®®p C A T�O N �CE 875(2-80) N�711 1�.L�i'�0�8 L� l�J+ FSA If"e ILS 6"i tl r1 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES 03i1g1L®I!1�iG 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 0.U ADU. RES Certified copy is hereby furnished. DING - ®� aP Lo+ALITY OF /UVal eprcopy is filed with the county building inspection ADDRESS NEAREST dt D JOF de artmtment. LocwLlTr V ceoss ST. (�faJ�/ Date Applicant NEAREST ^ _I ) DISTRICT NO. GROUP TYPE PROCES D BY CROSS ST. wY'•/ � CONSTI CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL .�✓ O ESCRI PTION LOT NO.�J 90 BLOCK COMPENSATION INSURANCE Md HIGHWAY }" No �0 (CIRCLE) STATE MA SECON D'LOCAL t1 _ NO. OF SLOGS. (This section need not. be completed if the work involved , NOW ON LOT ITRACT USE ZONE SPECIAL CONDITIONS to by the permit is .for one hundred dollars ($100) or less.) ' r!o V USE TI 1- �SIZE OF LOT EXISTING BLDG. (X 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 I— so as to become subject to the Workers'Compensation Laws. AIL OCCUPANCY GROUP ® W 'ADDRESS tL Date Applican% U) NOTICE TO APPLICANT: If, after making this Certificate of CITY No OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLICATION FOR111 -EXIT HARDWARE: with comply with such provisions Or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION - deemed revoked. C1 No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ( j 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 t effect. A l lC nt s Name PARKING. 3V Ilic PAIC E5 REQ"D O PROVIDED License Number ' Lic.Class Home Address — �— LIMITED TIME USE Contractor Date DATE ?ATE Fl. I am exempt from the licensing requirements as I am a. Phone FRAM: I TO: licensed architect or-a registered professional engineer s1.zE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES I SIGNATURE iness and Professions Code). —.o ode). FINAL APPROVAL y RESENT USE OF BUILDING �/ Lic.or Reg.No. Date ' HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS r ON LOT AND USE ' 1 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 i 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). PRorosED USE of1.000 UILDING CONSTRUCTION LENDING AGENCY 40r7i I hereby affirm that there is a construction lending agency .� I for the performance of the work for which this permit is 61 issued(Sec.3097,Civ.C.). + a o o u r'! Lender's Name' PROPOSED MAX. OCC. Lender's Address �pERNI1T FEE I c r i a o o r .I certify that I have read this application and state that the (ISSUANCE FEE I O Q, 6—bo aboue information is correct.I agree to comply with all County _ ordh1hnces and State laws relating to building construction, TOTAL FEE and-hereby authorize representatives/ f this County to enter upon the above-mentioned propert or inspection purposes. p�!!SEE REVERSE FOR EXPLANATORY LANGUAGE %�/�— g!/ 1 i' Signature of Perinittee Date i i WORKERS'COMPENSATION DECLARATIOI+ MISCELLANEOUS p g� @1 ° 20-0063DPW r 2/90 iV]i S G j.. t�!�.(�t !�.!�i='L.9 C:J±w Y U ! n I hereby affirm that 1 have a certificate of conscnt�to self COUNTY OF LOS ANGKLF.Sr 1BUILDING AND SAFETY DIVISION t, + `` insure.or a certificate of Workers'Compensation Insu once.or V f a..a certified copy thereof(Sec. 3800. Lab. C.) I Policy No. Company FOR APPLICANT TO FILL IN I BUILDING I BUILDING ADDRESS n — ADDRESS ' ❑ Certified copy is hereby furnished. 5-g e HI Q/ !, LOCALITY ❑. Certified copy is filed with the county building inspection CITY ZIP j y$f7 NEAREST p ` 7e Cr CROSS ST. i I Date Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT 1 DIST , qty GR P TYPE ESSED BY CONST. ' CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO. E } COMPENSATION INSURANCE 11 MAP HIGHWAY ', NO. ICIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work i9volved ASSESSOR MAP BOOK I PAGE PARCEL USE ZONE SPECIAL CONDITIONS I by the permit is for one hundred dollars (S100) or less.) ' TELNO �I ee I j! 1 certify that in the performance of Elle work for whi.h this OWNER TEL property? permit is issued. 1 shall not employ am person it any manner so as to become subject to the Workers* Compensatio-1 Laws. ADDRESS ' J' �- r m ) rr&V/,0 J OCCUPANCY GROUP IL r� JI Date Applicant i - CITY / I ZI co iIgo NOTICE TO APPLICANT: If. after making this Cer)::icate er II OCCUPANT LOAD of Exemption. you should become subject to the V};orkers' 01 APPLICATION FOR f EXIT HARDWARE: Compensation provisions of the Labor Code.you must forthwith i comply with such provisions or this permit shall be yeemed TRAILER USE_ GEOLOGY INSPECTION❑ j No Spec.Knowl. ❑ i revoked. — ElO:CUPANCY INSPECTION:� Panic Devices LICENSED CONTRACTORS DECLARATION I •--� 1 I hereby afl Ifni that I am li�ensetl under provisions Or(:-IapE2.- SAFETY PE IT J (LIST ITEMS BELOW. I NO.OF EXITS t 9(commencing with Section 7000)of Division 3 of the R.'sinss: and Professions Code and my license IS it, full force :1110 . le::. 11 PARKING• REO.DI I i PROVIDED License Number Lic. Class --- SPACES ! Contractor Date — t LIMITED TIME USE j DATE DATE ❑ 1 an-. exempt from the licensing requirements as [rani a 1+ FROM.: TO: a licensed arC1111eCi or :1 er r:clsted professions' c4aineei [} INSPECTOR'S r• I NO.OF r actin-^_In my professional cap:ckv(Section '051. ' B:tL Ine s SIZE OF EXISTING BLDG. STORIES ,! SIGNATURE and Professions Code). '' Llc. or Reg. No. Dat: PRESENT USE OF BUILDING 4 FINAL APPROVAL I� �� 01 I HOME OWNER-BUILDER DECLARATION it NO.OF EXISTING BUILDINGS ON LOT AND USE 1 hereby affirm that 1 am exempt from the Contractor's License -� C 0, Law for the following reason (Section 7031.5. Business and O/l 6'o d f9AAr� �1FVVA 6 1+ )f Frnfessions Code): NO.PARKING 6� - 0- SPACES PROVIDED A' ❑ 1. as owner of the property, will do the work agqld the j6 wl�h�N 044 qxP46W-/S structure is not intended or offered for sale (Sectio',. 704sx PROPOSED USE OF BUILDING Business and Professions Code). �i �� ,,,,c 11 �N� J/0-gvlraX� CONSTRUCTION LENDING AGENCY / IN r4U(i1SD PE/�i' - rs 1 hereby affirm that there is a construction lending agen'... for iS the performance of the work for which this permit is issued PROPOSED MAX.OCC. k S1g&f 0� U G. �� (Sec 3097,Civ.C.). / Lender's Name i APPLICANT IMNrI TEL NO. Lender's Address ADDRESS 1 certify that 1 have read this application and state blit the 1 O above information is correct. 1 agree to comply with all County PERMIT FEE ! I ordinances and State laws relating to building cnstructio)i.and hereby authorize representatives of this Count), to enter:upon ISSUANCE FEE n 1 the above-mentioned property for inspection purposes. ', i TOTAL FEE i x 7 SEE REVERSE FOR EXPLANATORY LANGUAGE • 1i�i 'I I Signature of Permittee Date i I. WORKERS*COMPENSATION DE('L.►R:tI'lON 76sn444 Y o� MISCELLANEOUS APPLICATION . c�875 t t•aar l.ilereby affirm that i have a certificate of consent to self ' insure. or a certificate of Workers'Compensation Insurance.ore COUNT . LOS .ANGELES If3UILDING .AND SAFETY DIVISION a certified cope thereof(Sec.3800.Lab.C.1. II +_ru Policy No. —i.itllp:rrly' I FOR APPLICANT TO FILL IN A.aOR IMG ADDRESS Certified copy is hereby furnished. BUILDING g•ADDRESS g LL'CALITY , ! I Certified copy is filed with the county building inspection LOCALITYK=AR EST t department. Temple City C OSS ST. Date Applicant_ rc EAREST �ISTR ICT NO GRO P TYPE derCESS CAEXEMPTION BY ROSS ST. ,�/ CONST' CERTIFICATE OF EMPT?ON F_RO1l'NORKERS' LEGAL •O�/ I COMPENSATION INSURANCE OE SCR IP7. LOT NO. (BLOCK tM.. AIGHWAT iCIRCLCI STATE MAJOR SECOND LOCAL NO. OF SLOGS. section sectuheed not lie conlpieted If the work involved -RACY -10W ON LOT isr TONE SPECIAL CONDITIONS by the permit is for one hundred dollar. 61001 or less.;(1( USOF II� 1 ' 1 SIZE OF LOT IE EXISTING BLOC. ! I I certify that in the verfonnance of :he work :o:which -his; permit is issuer{. I ,hall :lot employ any ?e-.sort !n any manner OWNER [ r so as to become iuhiect :o the Workers' C ampensation ?.a„c. MAI4 {/�� •�I p/(►1f�l�IAI 2 OCCUPANCY GROUP I — ADDRESS s- �O t 1J1VW fV i Date Applicant NOTICE TO APPLICANT: If. af:c: nakim :!tis Certficare ,I XI r.IT :IOL. ` Z I OCCUPAN-LOA% Exemption. you diould become iubiect :o the Wnrke Compenmrion provisions of rhe I..t<Ibor Cade. you must rorthrs'-. a L!CA71CN -DR 1 -VT HAROtNARE with CUltlniy with .ueh nrovisll,Ior his '`ernin illall he — t ? -RAILER USE I GEOLOGY GY :NAPE.-T!ON deemed:e%oked. � _ I No Spec. I<is vi. � OCCUPANCY INSPECTION= Panic Devises ❑ N LICENSED CONTRACTORS DECLARATION =+ I hereby- affirm :hat i am licensed under,provisions of CilapterJ „I1 SAFETY PERMIT LIST ITEMS BELOIN) I((II I 9 (C0111117encine, with Section '000) o Division .lI ille 1iUSI- I' NO. OF EXITS vi ncss and P-L,I'cxsinm('ode..utd my license i. in title f,,rce and et?eli. 1 PARKING REO'O I 1 PRCVID ED SPACES License Number Lic. Class i o LIMITED TIME USE WContractor ......__ ------- Ilate--.._-'—_. I Dare DAnc Z n q^fA: TO: J 1 and exempt from the :icensing rettuucments as 1.am I f• licensed are irect or a :esistered professional eneineer. 31zE of .,o. of INSPECT R'S 2 actin_ 111 niv prcfes;lona! mra_ii 5,!:-.ion -j1;1. Iiiii. EXISTI9+ SLcr, STORIE3 SI AT RE ainess and Professiem t,,del. I L S - - —_— I-- - U I 'RESENT USE OF 3 1 N A L A PP R O UILDING �� V Lic.or Req. No. --- Daw___-. 1 l �A 11011E O11'Ni R-li l'ILDER DE('L•.\1t.1111)N AAS I' NO. OF EXISTING BUILDINGS - /' �� t ON LOT AND USE V Ila I hereby ,ii:irm that I .un exempt from the Contractor*� 1 - License Law for the following reason 1Section -031.5. Busi' k17 ness and Professions Code i: NO. PARKING /I 1, as owner of the-property. will do the ,Fork and the SPACES PROVIDED structure is not intended or offered for tale (Section 1 704.1.1111,ilIC<,and Professions Codel. +1 CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING "AAA. 1299AUL +. I hereby affirm that there is a consiniction lending agene” 1 for the performance of the work for which this permit b issued ISee. 3097,Civ.('.I. Lender's Namc.____—_--• __—_-. ; i I, PROPOSED MAX. OCC. Lender's.address ! I certify that I Have read this application and state that thii PERMIT FEE 25.00 above information is Correct. I agree to Comply with all Comity ISSUANCE FEE I IX11 ordinances and State laws relating to building construction, M ! and hereby authorize representatives of this County to enter TOTAL FEE 25.00 upon the abo c-mentioned p o erty f r inspection S. SEE RE'':ERSE FOR EXPLANATORY LANGUAGE rpos 0. 1 SigratUre of 1'crmittL Date WORKERS'COMPENSATION DECLARAIION ' '""'"'" • : 1NI-ISC ELLANEOIJ'S APPLICATION 20-0063DPW12/90 L hereby affirm that I have..a certificate of consent --(self 'COUNTY OF LOS-ANGELES BUILDING:.AND SAFETY DIVISION J'..•4`tbsure,or a certificate of.Wdr7ters'Compensation Insurance•or a certified•copy thereof(Set;:3800, Lah C)-' I +'' -Policy'No. Company i FOR APPLICANT TO FILL IN 13UILDING .,I '• ' ' '•t• I BUILDING ADDRESS ADDRESS ` 'moi• t7 Gj 1 ❑ Certified*copy.is.hereby..furnished. g Ey{e. LOCALITY ! ❑ Certified copy is filed'with the county building inspection CITY ' ZIP department. T•G '(� (� 1700D 1 NEAREST W pp�i/yyI� it CROSS ST. i:: ' Date %'• Applicant ' SIZE OF LOT dNO.OFE[:DGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY d CONST. CERTIFICATE OF EXEMPTION FROM WORKERS'f TRACT BI_ocK Lor No. C ,COMPENSATION INSURANCE NO. c,RNCLIn STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCELC by the permit is for one hundred dollars ($100) or less.) USE ZONE SPECIAL CONDITIONS L certify that in the performance.of'the work for which this sr er LNo. I permit is issued:I shall not employ any person in any mariner _#ViS I so as to become subject to the Workers' Compensation Laws. ADDRESS y G g � (S Z OCCUPANCY GROUP Date Applicank CITY,r ZIPQ(? NOTICE TO APPLICANT: If; after making this CertificatebA- OCCUPANT LOAD of Exemption.. you should become subject to the WorKers' UAPPLICATION FOR i Compensation provisions of the•.I�lior Code,you must forthwith EXIT HARDWARE: comply with such provisions or this permit shall be deemed TRAILER USE El GEOLOGY INSPECTION❑ No Spec.Know!. revoked. ' ❑ LICENSED CONTRACTORS DECLARATION I OCCUPANCY INSPECTION i Panic Devices ❑ I 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) i ( 9(commencing with Section 7000)of Division 3 of the Busi(less I NO.OF EXITS and Professions Code.and my license is in full force and effect. :. ame o u ess I' PARKING• REO'D O PROVIDED License Number Lic.ClassI I . I �L N PRYC��yy/NC7 7rla�A►r �•�GT�ATo�� SPACES) Contractor Date ! LIMITED TIME USE I I �� i ElI am exempt from the licensing requirements as I a I' a DATE DATE ' licensed architect or a registered professional engineer {'FROM: To: ' SIZE OF t� NO.OF INSPECTOR'S acting in my professional capacity(Section 7051,Business EXISTING BLDG. °t 1�Otl 1 and Professions Code). sroR1E$ SIGNATURE. ! - Date I. PRESENT USE OF BUILDING 54_1hl IFINAL APPROVAL Lia or Reg.No. 1t nws ' 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 703 1.5, Business and Professions Code): 1 NO.PARKING ! r 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, PROPOSED USE OF BUILDING f Business and Professions Code). I l I CONSTRUCTION LENDING AGENCY f i' I hereby affirm that there is a construction lending agency�br 1 the performance of the work for which this permit is issued I ' I (Sec 3097,CIV.C.). PROPOSED MAX.OCC I Lender's Name APPLICANT!PAIN[) TEL NO. I' cII A-M COUT UtA^ 6-j.6-Y 1—oft Lender's Address ADDRES I certify that I have read this application and state that the 4 LV- � � n7B,'I 'ft� iwf"91 above infonnation is correct I agree to comply with all County PERMIT FEE ' ordinances and State laws kelating to building construction,and hereby authorize representatives.of this County to enter upbn ISSUANCE FEE the above-mentioned property for inspection purposes 4 TOTAL `(� - -• I:: "•i r ..Y' .. l L FEE REVERSE FOR EXPLANATORY LANGUAGE ' Signature or Permittee Date