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y y WORKERS'COMPENSATION DECLARATION ' 44
CE 875(71.84)
WTSC E L LA N E O U S APPLICATION
CE$
I rbaffirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, o or a certificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.C.).
t_J Policy No. Company FOR APPLICANT TO FILL IN BU,1LDING �f
Certified copy is hereby furnished. BUILDING ADDRESS _ 4;?7
/
ADDRESS�1-7 (. M b Uy'd, LOCALITY
i Certified copy is filed with the county building inspection LOCALITY NEAR EST
department. CROSS ST,
Date Applicant NEARESTc DISTR I� G pGRO P TYPE G£SSED BY
CROSS ST. .3 jj(/ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MA. HIGHWAY
NOOF LDG$, IV
O; (CIRCLE) STATE MAJOR SECOND LOCAL
.
(This section need not be completed if the work involved TRACT NOvr ONBLOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (5100) or less.)
USE or
{ ,I SIZE OF LOT EX STING BLDG.
I certify that in the performance of the work for which this
permit is issued. I shall not employ any person in any manner OWNER _ _ gr ��O�t Z f�
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP V
woDRESS fe Lz��
(�L Zrt GI/ d
1 Date Applicant
g C.A410G0C GS TEL. `738 OCCUPANT LOAD
NOTICE TO APPLICANT: If,after making this Certificate of tlxY No. ,T.(o ,Z. --
Exemption, you should become subject to the Workers' i _
Compensation provisions of the Labor Code,you must forth APPLICATION FOR EXIT HARDWARE:
1 with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION
deemed revoked. E GI No Spec. !<nowl.
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION$[ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
n ) SAFETY PERMIT (LIST ITEMS BELOW)
N 9 (commencing with Section 7000) of Division 3 of the Busi- Na. OF EXITS
ness and Professions Code,and my license is in full force and f(�tI
effect. PARKING REWD �! PROVIDED I I
y SPACES l 2
o License Number Lic.Class LIMITED TIME USE
LL
fNA Contractor Date LATE DATE
W
1 I am exempt from the licensing requirements as I am a FROM: TO:
m f licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
Z acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STQRlES SIG URE
m iness and Professions Code).
U PRESENT USE OF BUILDING FINAL APPROVAL
U Lic.or Reg,No. Date
i
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ,y
ON LOT AND USE n
I hereby affirm that I am exempt from the Contractor's ;
1 License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): I NO.PARKING
I, as owner of the property, will do the work and the ti SPACES PROVIDED
structure is not intended or offered for sale (Section
i 7044,Business and Professions Code). {
CONSTRUCTION LENDING AGENCY X` PROPOSED USE OF BUILDING i
I hereby affirm that there is a construction lending agency 6 Q
1 for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q. Z
Lender's Name ID
PROPOSED MAX. OCC.
Lender's Address
i I certify that I have read this application and state that the PERMIT FEE 25.00
above information is correct.I agree to comply with all County ISSUANCE FEE t—* TM
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL.FEE 25.00
upon the above-mentioned property for inspection purposes.
%r D�i rt 1e � SEE REVERSE FOR EXPLANATORY LANGUAGE 1"
Clt:n ltnre of Permittee Date a
_ Frn
WORICL-RS'C'OMPLNSAIION DLCLARtIflON i11111 MI5GELLANEOUS APPLICATION
I hereby affirm that I ha eertil'ieale of* �,uhent t„ ,eh C'OUN'l l' OF IOS ANGFI FS BliII.DING AND SAF-ETY DIVISION Il
1 insure,or it certificate ul \\urhers•olinpcn,:nunl lu,ul.ulce.or
a certified cup) lhcreol (Sce. moo. I al). (•.1
Policy No. -• Company FOR APPLICANTTO FILL IIJ BUILDING
BUILDING ADDRESS ADDRESS
❑ Certified copy is hereby furnished. .;5 g77— -T MPL)_; CA LV1 _ LOCALITY
❑ Certil'ied copy is I.ded with the cuunly building In•.I,rcllun CITY_ �y -- ziP -- —
department. IP-J\P� L/t_f �17�� — NEAREST
CROSS ST.
Date Applicant SIZE OF LOT INO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY
1
CERTIFICAIL OI' l:Xl:N1P11ON FROM WORKI.R.S' - -- — ('
,tet OMPL'NSAI7ON INSUR AN( l: Trracr CONST.
C BLOCK LOT NO. MAN HIGHWAY �•
_ No ,CIRCLET STATE MAJOR SECOND LOCAL
(This section need not be completed if Illi• viork ill%ohed ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS r'
by the permit is for one hundred dollars (S 1001 or Ie%%.) e —
t
certil' that in the performance tit' the "ork IIv ahwij 1111,
+.i I permit is issued. I shall not employ an) person nl .sly ru,uuler ��E
so as to become suhjccl to the Workers' (umpen,aliul( Lau,, (ADDRESS , OCCUPANCY GROUP 1,
IS1
Date Applicant CITY �� � z)p 1790 --
NOTICE TO APPLICANT: If. alter making this Certificate P� OCCUPANT LOAD
of Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code.you must 1`01thwilli
Comply Will] SACT( pro%15111115 lir this permit %hall be deemed TRAILER USEE]
L-1 GEOLOGY INSPECTION�I
I revoked. No Spec.Knowl. 1:1
! LICENSED C'ONTRAC'TORS DLULAR \'I ION OCCUPANCY INSPECTIONrr�� Panic Devices ❑
I iI hereby'off Irin that I am licensed under provisions of('hllpll'f SAFETY PERMIT O (LIST ITEMS BELOW I
9(commencing with Section 7000)of Di%inion 1 of the Business NO.OF EXITS
and Professions Code,and my license is in full Ibrce and effect.
PARKING• REq'D � PROVIDED D
License Number l..lc. ('I;[-,s SPACES
1 I Contractor Date -- —•— ------ -----•---- --- ----- LIMITED TIME USE
ElI am exempt from the licensing requirementsas I :1111 it DATE DATE
FROM: TO:
E licensed architect or it registered prolessional engineer
:ICllllg II) 111)' pr(1fL`ssll,ll:ll L'il1)ill'll) (Section 7(li 1, ltll,lll('s, SIZr OF NO.OF 9 INSPECTOR'S
1 EXISrIN(.B1.0G. �� STORILS 1 SIGNATURE
and Professions Code). ----- —_-- _—_-- -
I
Lic. or Reg. No. Date PRESENT USE OF BUILDING v���I FINAL APPROVAL
IIOA9l OWNER-lillll.l)I.IL I)I.l I..AI(:\I ION r„I Dr 1 XI_.IINGBUILDINGS
I ,IN 1.07 AND USE
I hereby affirm that I ani c\cnipt front the Contractor's i Ir(ns( - -- ---------- -- - ---
Law for the lolltming reason tSectiun 7011.1, Business and _
1 Professions Code): NO.PARKING
El L as owner of' the properly. „ d
ill ., the ,,,,rk .Ind thSPACES PROVIDED
r — — -- --- ----
structure is not intended or utleled I0i sale(Seellull 1111.1. PROPOSCE)USE OF1311ILDING
I 13u5ine5s and I'rofession5
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a cunstrucuun ICndiue
the performance of the uork for „hick this permit is Issued - --" ------- --
ul
(Sec. 1097.Civ.C'.). PROPOSED MAX.OCC.
I Lender's Name - _ APPLICANT I mejT, • TE4 NO
X VA. tlr4 bJC�TRAV(�ITQAI�I Dz10-�g 3;oc
Lender's Address ADDRESS
1 certify that I have read this application and slate 111,11 the
above information is correct. I agree to Comply Willi.111 r(1111111)• PERMIT FEE
I ordinances and State laws relating building construcuan.and
hereby authorize repres ntative•pF this County to enter upon ISSUANCE FEE
the •bove-menti a ropert• o )cetiun purposes.
�1 I TOTAL FEE
X SLE REVERSE FOR EXPLANATORY LANGUAGE
Signature or P nnittee p.qe
f
{ I i WOILICJ:K.� CUIV1Y1r)VJAl1UlV LCI.LAt(Al1VIV 20-0063DPW12/90 1Vll�L.C.LVV:� H!''1''Ld1L.H1 1VlV
4; hereby affirm that I have.a certificate of consent to self COUNTY OF LOS-A' N'GELES 'BUILDING.AND SAFETY DIVISION 1�
• mre,or a certificate of•Workers'Compensation Insurance,or - • `I I
i�
certified copy thereof(Sed:3800,Lah C.)-
I licy•NO. Company FOR APPLICANT TO FILL IN BUILDING
Y I- "• BUILD IVG A ADDRESS
copy.isheby: urnishedA�
Certifie
19 1
'• ertified copy is filed'with the county buildin nspection cl NEAREST•I I . ZIP NEAREST
d artment
� CROSS Sr.
Date %' Applicant SIZE L T NO. BCDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY
CE ICATE'OF•EXEMPTION FROM ORKERS' CONST. C
(' F COMPENSATION INSURAN E TRACT BLOCK LOT No. MAP HIGHWAY k
(This sectio need not be completed if he work involved I "� IClwclel STATE MAJOR SECOND LOCAL..
P ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS O
I by the perms is for one hundred doll rs ($100) or less.)
( I I.certify that in he performance.of t work for which this
i�r er ,T
I permit is issued'I hall not employ an person in any manner
I so as to become su 'ect to the Wor rs' Compensation Laws. A ss t OCCUPANCY GROUP a
( I Date Applic nt . c z)
NOTICE TO APPLICA If. a er making this Certificate '"' OCCUPANT LOAD
of Exemption, you shout be a subject to the Workers' 0 APPLICATION FOR
Compensation provisions of t e- or Code,you must forthwith EXIT HARDWARE:
comply with such provisions r this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑
' revoked No Spec.Knowl. ❑
' OCCUPANCY INSPECTION Panic Devices ❑
LICENSED CONTR S DECLARATION
I hereby affirm that I am tic Sed der provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW)
( I 9(commencing with Section 000)Of iviSion 3 of the Business 31 game o Business NO.OF EXITS
and Professions Code,and y license is ' full force and effect. .
PARKING• D D
' I License Number Lic.Cl s j � � SPACES REQ'D PROVIDED
I I I Contractor Date U LIMITED TIME USE
i DATE DATE
❑ I am exempt rom the licensing requiremen as I am a
• I FROM: TO:
licensed ar itect or a registered profession engineer
acting in professional capacity(Section 7051, usiness SIZE OF NO.OF INSPECTOR'S
'{� 1 ; '• and Profe ions Code). EXISTING BLDG. STORIES SIGNATURE.
Lia or Reg. o. Date PRESENT USE OF BUILDING FINAL APPROVAL
I I
ME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS
ON LOT AND USE
i I he y affirm that I am.exempt from the Contractor's License
La for the following reason (Section 7031.5, Business and
( I P fessions Code): NO.PARKING ACES PROVIDED e 0
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 OM 90aJ
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. PROPOSED MAX.OCC
Lender's Name APPLICANT( 17-1111
Lender's Address
iI certify that I have read this application and state that the A
above information is correct. I agree to comply with all County PERMIT FEE
I ordinances and State laws ielating to building construction,and
hereby authorize representatives of this County to enter upon ISSUANCE FEE y-
(( .•+ ',I the above-mentioned property for inspection purposes. -- -• .
1, I -! • TOTAL FEE
% SEE REVERSE FOR EXPLANATORY LANGUAGE
� Signature of Permittee Date '