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HomeMy Public PortalAbout5910 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 p� p p p p ! ® /� w' CE 875 (2-80) MISCELLANEOU!§ 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.) P Policy No. Company FOR APPLICANT TO FILL IN PDD REsS v ❑ Certified copy is hereby furnished. uILDING y� O h aMPM e-)-' RL.VD . LOCALITY �+ ADDRESS l7 �'I=i� J/ ❑ Certified copy is filed with the county building inspection NEAREST department. OCALITY 2IE I CROSS ST. Date Applicant ! AREST nFr T la QC ))'yam DISTRICT G UP PE IPROC SED BY CROSS ST. 1�6 / (4ry'JV R. vt� _ CONST.'/ CERTIFICATE OF EXEMPTION FROM WORKERS' I DESCRI TION LOT NO. BLOCK MAP , HIGHWAY `/ `r LEGAL COMPENSATION INSURANCE NO. OF LOGS. NO.. (� (CIRCLE) STATE MAJOR SECOND LOCAL tl (This section need not be completed if the work involved TRACT NOW ON LOT USE Z15NE SPECIAL CONDITIONS 0 by the permit is for one hundred dollars ($100) or less.) U USE OF SIZE OF LOT EXISTING BLDG. 1 O I certify that in the perTormance of the work for which this �/ permit is issued, I shall not employ any person in any manner ' OWNER U so as to become subject to the.Workers' Compensation Laws. AIL Al. �y /� OCCUPANCY GROUP LU Date Applicant I ADDRESS 6116 6 A I-x4 f 4 \ray Ri-jo n- NOTICE TO APPLICANT: If, after making this Certificate of ! Iry 7EA41E Z.47/ ToI �p (S 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 such provisions Or this permit shall be I TRAILER USE❑ GEOLOGY INSPECTION NO Spec. Knowl. ❑ drPemed revoked. Panic Devices E]LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter ! SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS E:19 (commencing with Section 7000) of Division 3 of the Busi- iks and Professions Code, and my license is in full force and effect. I PARKING SPACES REO'D E== PROVIDED 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 NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- E (STING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL Jr' RESENT USE OF BUILDING Lic.or Reg.No. Date � s74U .tom' �3��5 siva s V HOME OWNER-BUILDER DECLARATION I NO.OF EXISTING BUILDINGS ON LOT AND 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, as owner of the property, will do the work and the I 3 5 8 n A structure is not intended or offered for sale (Section p 7044,Business and Professions Code). PROPOSED USE of BUILDING 0 0 0 o 88 o 0 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency I c7� olJ r I, 20-84 G_8 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name I PROPOSED MAX. OCC. Lender's Address I 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 i ISSUANCE FEE ordinances and State laws relating to building construction, ' TOTAL FEE and hereby�thor* resentatives of his County to enter ) �on the ad pror Ins ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 6- , Signatur f rm) tee Date I � WORKERS'COMPENSATION DF.,CLARATION I CE 875(2-80) MISCELLANEOUS ������S(a!�E®9�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' rs'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab C.) Policy No. Company I FOR APPLICANT TO FILL IN BUILDING /f OADDRESS Certified copy is hereby furnished. I BDUILDING DRsss_gglC> X&I :;pe, �`� C� �! j,OCALITI , Certified copy is filed with the county building inspection NEARCST department. I LOCALITY �J/J� / / / fI CROSS ST. Date Applicant NEAREST /L !r V / DISTRICT NO. GROUP CONST PROCE ED B CROSS ST ",_5 S CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �.4 COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK MAP �fie) HIGHWAY (�C. STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved! NO. OF BL T USE ZONE S ECIAL CONDITIONS 0 P TRACT NOW ON LOT [� by the permit is for one hundred dollars ($100) or less.)% USE OF y U I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. X permit is issued, I shall not employ any person in any manner,A OWNERAV /)V SLIj17© L O so as to become subject to the Workers'Compensation Laws. MAIL G.. OCCUPANCY GROUP X AD.RES �,,,J 5 ,L/ �/��� Date Applicant SAsq �� ,(� TEL —� NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. �O OCCUPANT LOAD yJ ' 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 No KnOWi. ❑ deemed revoked. ❑ OSpec. ❑ Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 11 _ I hereby affirm that I.am licensed under provisions of Chapter i 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 PARKING. effect. REG'D O PROVIDED O SPACES License Number Lic.Class dJ/ LIMITED TIME USE Contractor Date DATE DAT E 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). FINAL APP R OV A L PRESENT USE OF BUILDING /J C� (� /i/! i �� f- C�} : •- , Lic.or Reg.No. Date Oft_57V V i HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS � ON LOT AND USE I hereby affirm that I am exempt from the ContraLtor's License Law for the following reason (Section 7031.5, Busi KING ness and Professions Code): SPACES PROVIDED ;2333.8A ❑ I. as owner of the property, will do the work and the structure is not intended or offered for sale (Section # o o O o 4 0 7044,Business and Professions Code). PROPOSED USE OF BUILDING o 0 0 0 0 0 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency i 1208-80 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 he by authorize representatives of this County to enter upon he' ove-mentioned roperty for inspection purposes. SEE REVERS I'OR EXPLANATORY LANGUAGE Signature offPerrpfttee IV Date yyJR:;ERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I hert;)y affirm that I hare"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.) FOR APPLICANT TO FILL IN BUILDING AA Policy No. Company ADDRESS �U s ❑ Certified copy is hereby furnished. AVILDIN b F-1DDRESS —% LOCALITY q Certified copy is filed with the county building inspection NEAREST department. LOCALITY Aif /�. A / CROSS ST. , Date Applicant AREST �I ,('(f/ L C/� DISTRIC NO. GrrI .j TYPE / PRO ED BY GROSS ST. 44s /U J, d/z, �(^�, CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I u DESCRIPTION LOT NO. BLOCK n COMPENSATION INSURANCE NOP r ��Rc E) STATE MAJOR SEC D LOCAL Q NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars (S100) or less.) USE of /p SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this VE Q permit is issued, I shall not employ any person in any manner WNER 41119A10,-- so as to become subject to the Workers'Compensation Laws. AIIIL Q 7 OCCUPANCY GROUP W ADD ESS 0�6 DW,• ` L CL Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of CITY i �. CEJ. 90Qb5 TEL j3 2�9e268 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❑ Y P ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El 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 KING R effect. SPPAACES REQ'D D PROVIDED D License Number Lic.Class • LIMITED TIME USE Contractor Date DATE DATE F1FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF No. OF IPE CTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IGNATURE iness and Professions Code). 7 9/0101rP/ � / FINAL APPROVAL SENT USE OF BUILDING �(/ (/CJ Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that 1 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, 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). osED USE OF BUILDING /J OT J /29N z2490A CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency # o 0 0 0 8 8 for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). 0 0 0 0 0 0 0 z Lender's Name PROPOSED MAX. OCC. 07, 18-85 Lender's Address PERMIT F7.—. — 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 B.�U and hereby authorize regplesentatives of this County to enter upo the above-mentiosjsg' roper inspection purposes. SE REVERSE FOR EXPLANATORY LANGUAGE Allir0 ddature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 876(2-e0) MISCELLANEOUS A I'P L ICAT 10 N� I hereby affirm that 1 have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' rs'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN ncuRESS /U ❑ Certified copy is hereby furnished. UILDING ADDRESS LOCALITY S O t r-1Certified copy is filed with the county building inspection NEAREST department. OCALITY CROSS ST. 6 Date Applicant >eAREsT DISTRICT NO. GROUP TYPE OCE ED BY CROSS ST. U 5 `^`u n 6­4CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J TJ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP/S– HIGHWAY CL ✓—� STATE MAJOR ...... .OCAL NO. OF BLOGS. NO. Y(CIRCLG) CL (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 (S100) or less.) USE OF U I certify that in the SIZE OF LOT EXISTING BLDG. y performance of the work for which this0 permit is issued, I shall not employ any person in any manner �+ IER ��(N�� SCO AQL I— so as to become subject to the Workers' Compensation Laws. L OCCUPANCY GROUP W DDRESSd Date Applicant a `C V to NOTICE TO APPLICANT: If, after making this Certificate of eTTY &Ali CC + o. $ 4J`O?—111 OCCUPANT LOAD z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPI11CATfON FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION NO Spec. KnOWi. ❑ deemed revoked. P LICENSED 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 a 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. REO'D O PROVIDED O SPACES License Number Lic.Class LIMITED TIME USE Contractor Date O ATE D AT E ❑ 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 my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL ENT USE OF BUILDING 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, Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED EJ 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section /.A 7044, Business and Professions Code). 111roPOSED USE OF BUILDING 5 7 3.6 A CONSTRUCTION LENDING AGENCY # 0 0 0 0 8 8 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 110 0 0 0 0 0 0 0 In issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. I G22-86 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 au ize representa es of this County to enter upon t a ve-menti d pr y for inspect on urpoS. / SEE REVERSE FOR EXPLANATORY LANGUAGE 17 Y `0 �6 P7 Signature of Permittee D to I WOT;KERS'COMPENSATION DECLARATION CE 8754(11-a4) MISCELLANEOUS!APPLICATION I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insurti, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING 0 A A-T ADDRESS Certified copy is hereby furnished. BUILDING �D V a/! 1� f /�1` LOCALITY ADDRESS Ay Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. AA Date Applicant NEAREST 01ST-RI T/IGO. G UP TYPE PR SE BY CROSS ST. �/�S/\� YY CON7q-r CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECUO LOCAL ND. (CIRCLE) NO. OF BLDGS. (This Section need not be completed if the work Involved TRACT NOW ON LOT USE ZON SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) use of r SIZE OF LOT EXISTING BLDG. (� I certify that in the performance of the work for which th' o permit is issued, I shall not employ any person in any manner OWNER6'0 so as to become subject to the Workers' Compensation Laws, MAIL /V , — OCCUPANCY GROUP o Date Applicant ADDRESS GCC/. NOTICE TO APPLICANT: If, after making this Certificate of CITY C e No� J j �[ ,� —JJ// , 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 such provisions or this permit shall be TRAILER USE E] 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) 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. PARKINGREQD PROVIDED 1�—J SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: licensed architect oI a registered professional engineer SIZE OF NO.OF, )NSP NATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). PRESENT USE OF BUILDING � FINAL APPROVAL Lic.or Reg.No. Date / CJ 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 I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 2 b 8 9.8 A 7044,Business and Professions Code). PROPOSED USE OF BUILDING 0 0 0 0 $$ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency o o D o D o o in for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. 0 IL 2 4=8 7 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, ��J`�� hereby authorize representatives of this County to enter TOTAL FEE u on the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION ICE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self I insure, or a certificate of workers'Compensation Insurance,or COUNTY OF LOS ANQELES- BUILDING AND SAFETY DIVISION �1 a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BpDDRE55UILDING �^((]] �,�11 Certified copy is hereby furnished. XX ADDRESS J—t I V JJ. Trwpfeclt ✓EL , LOCALITY J E Certified copy is filed with the county building inspection LOCALITY NEAREST department. XX CROSS ST. Date Applicant NEAREST /�`T /�! DISTRICT NO. G UP TYPE CESSED BY CROSS ST. LQ5 i�'�^`� Or ' OFW-5 -2 CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL G J COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) (This section need not be completed if the work involved TRACT NOW O OF BLOT S. USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of ' SIZE OF LOT EXISTING BLDG. Q I certify that in the performance of the work for which this �v o permit is issued,I shall not employ any person in any manneRX OWNER of building G ,i/,� —e- so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP ® o MAIL �J r Date Applicant ADDRESS NOTICE TO APPLICANT: If,after making this Certificate ofCITY NO. 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 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 anX effect, Name of business PARKING REO'D 1 I PROVIDED E:= LL SPACES 11_�� License Number Lic.Class 1&� J rl n r LIMITED TIME USE Contractor Date C ATE DATE FROM' TO. INSP TORS I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES ' SI ATUR6 iness and Professions Code). J FINAL APPROVAL ZZ Lic.or Reg.No. Date PRESENT USE OF BUILDING S r_ I-10ME OWNER-BUILDER DECLARATION NO.OR 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- l o E 8/ 1/9' , ness and Professions Code): NO.PARKING Y I, as owner of the property, will do the work and the SPACES PROVIDED 1� IE 163° 1 1�a`--F'M 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 above information is correct.1 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 25-00 I upon the abov%e-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE XX � .2214111 _ XX ienature Pcrnrittce Date WQRKERS'COMPENSATIONDECLARATION . 6M444 MISCELLANEOUS APPLICATION CE 875(h 1-84) �I he'reby affirm that 1 have a certificate of consent to self , N COUNTY OF LOS ANGELES BUILDING ADIVISION insure, dr a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.Q. r Policy No. Company FOR APPLICANT TO FILL IN [.OUDDRErg: ICertified copy is hereby furnished. X ooRess ALITYCertified copy is tiled with the county buildig inspectio, OCALITY RESTdepartment. xX Commercial area ss ST. Date Applicant AREST TRIC NO. GRQuP JTYffMCE. BY CROS§ST. fj( OgP CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 3 COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP ' HIGHWAY ND. (CIRCLE) STATE MAIOR SECOND LOCAL OF BLOC (This section need not be completed if the work involved TRACT NOON LOT S. W USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE ofA%/ 1 certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. >- 1 D_ permit is issued,1 shall not employ any person In any me ekX. OWNER-of building so as to become subject to the Workers'Compensation La I MAIL OCCUPANCY GROUP C",- ADDREss 1"6g7T_r-Eac.ificcAve. r- Date Applicant 4 NOTICE TO APPLICANT: If,after making this Certificate of ti CITYVeniee No`'( 31o) 479-766C OCCUPANT LOAD vi 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❑ No Spec. Knowl. deemed revoked. - LICENSED CONTRACTORS DECLARATION oceurwNcv INSP96T1oN❑ 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 Bu I No.of Exlrs ness•and Professions Code,and my license is in full force a• XI Name of business PARKING effect. r SPACES REO'D D PROVIDED License Number _-_—Lic. Class i, BO BO Chinese Restaurant i JJ LIMITED TIME USE Contractor Date DATE DATE y PROM: TO: 1 am exempt from the licensing requirements'as I am a I I licensed architect or a registered professional engineer } III"OF NO.OR INSPECTORS acting in my professional capacity, (Section-7051, Bus. EXISTING BLDG. STORIES SIGNATURE mess and Professions Code). IPt APPRI– FI% _Zt_q�J •� PRESENT USE OF BUILDING O•VAL Lic.or Reg.No. Date ' HOME OWNER-BUILDER DECLARATION �' NO. OF EXISTING BUILDINGS I 9/ 6/9f- ON LOT AND USE ' 1 hereby affirm that I am exempt from the Contractor's ' d �j , License law for the following reason (Section 7031.5, Busf- „/nV ness and Professions Code): o.PARKING SPACES PROVIDED I, as owner of the property, will do the work and the f N ; structure is not intended or offered for sale (Section 7044,Business and'Professions Code). CONSTRUCI'ION LENDING AGENCY PROPOSED USE OP BUILDING hereby affirm that there is a construction lending agency r for the performance of'the work for which this permit is issued(Sea 3097,Civ.Q. Lender's Name. , PROPOSED MAX.OCC. Lender's Address PERMIT FEE 2-9.00 I certify that 1 have read this application and state that the above illfotmation:is correct.I agree t0 Comply with SII County ISSUANCE FEE ordinances and State laws relating to building construction, and heby'authorize representatives of this County to enter TTAL OFEE' 25.00 upon i above-mentioned prop rty for inspection purposes: r I a SEE REVERSE FOR EXPLANATORY LANGUAGE \ 1/. BX