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Home My Public Portal About5928-5934 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION I herby aff'i'rm that I have a certificate of consent to self CE 875(11-84) insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES �� BUILDING AND SAFETY DIVISION a certified copy thereof(Sec. 3800,Lab.Q. �. . Policy No. Companyi FOR APPLICANT TO FILL IN ADDRESS ryf Q ��. Certified copy is hereby furnished. BUILDING 66) 0 � �! Jj, ,11� LOCALITY ADDRESS r7VV(�✓ F] Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST r 1� D(STRIC NO. 6R UP TYPE PRO ESSED BY CROSS ST. UNr J �j Q`�/� i CON CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) 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 SIZE OF LOT EXISTING BLDG., G o` I certify that in the performance of the work for which this o permit is issued,'l shall not employ any person in any manner OWNER SZ, so as to become subject to the Workers' Compensation Laws. MAIL ��vp�� OCCUPANCY GROUP o AD D R E S S Q�/90 G(/JLi'_ Date Applicant 5�z-_ - ---- U; TE '-'-' OCCUPANT LOAD NOTICE TO APPLICANT: If,after making this Certificate of CITY � � / No. �� d 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 oI this permit shall be TRAILER USEGEOLOGY INSPECTION deemed revoked. ❑ ❑ No Spec. Knowl. 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 ' KINGeffect. Lc RREO'D PROVIDED ^ SPACES License Number Lia Class LIMITED TIME USE Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Blas- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). �SFINAL APPROVAL _ PRESENT 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 nLicense Law Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING y _I_ ❑ 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). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING e, 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 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, and hereby authorize representatives of this County to enter TOTAL FEE ° upon the abo e-m Intioped roperty for inspection urpgses. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Ped'Ri'ft¢ee Date .� WORICtRS'COMPENSATIONDECLARATION E 875(11-84) CMISCELLANEOUS 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.C.). Policy No. Company FOR APPLICANT TO FILL IN FADDR9 ILDING SS Certified copy is hereby furnished. BUILDINGI AD DR ESS I� CALITYCertified copy is filed with the county building inspection LOCALITY REAK STT. department. OSS Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. (� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO.OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) use OF SIZE OF LOT EXISTING BLDG., I certify that in the performance of the work for which this _ _ AF o permit is issued, I shall not employ any person in any manner OWNER o so as to become subject to the Workers' Compensation Laws. gNt R r OCCUPANCY GROUP MAIL ADDRESS 1--' Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. 9/00 6 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 USEGEOLOGY INSPECTION ❑ E] ElNo 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 effect. d PARKING R9 WO PROVIDED �� License Number Lic. Class SPACES I LIMITED TIME USE Contractor Date O ATE DATE FROM: TO: i ECTOR'S 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 sl ATUR iness and Professions Code). PRESENT USE OF BUILDIN-Af FINAL APPROVAL Lic.or Reg.No. Date A4 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's r r, _ y," *l r4 License Law for the following reason (Section 7031.5, Busi- ,.1-'IIt ��`_i J%it/ ness and Professions Code): No. PARKING 324304 A*iy;5? SPACES PROVIDED El 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). 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 PERMIT FEE I certify that I have read this application and state that the above information' correct.I agree to comply with all County ISSUANCE FEE ordinances and to laws rely ' to building construction, and hereby aut rite represe iv of this County to enter TOTAL FEE -upon the abov ent' p y for inspection purposes. v SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date WORKERS'COMPENSATION DECLARATION I 875 (2-80) CE MISCELLANEOUS APPLICATION s CE 875 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,lor or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN ABUILDING ❑ DDRESS Certified copy is hereby furnished. 06bILOING • ��/ /�_ „lyt LOCALITY ❑ ADDRESS Certified copy is filed with the county building inspection NEAREST department. Lo ALITY C/T CROSS ST. Date Applicant ooEAREST DISTRICT 11I��ll�g9 G OUP TYPE PRO ED BY CROSS ST. -7.4S /'�/' . � CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (�0 COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY } NO. (CIRCLE) STATE MAJOR SEC D LOCAL d 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 (5100) or less.) USE OF SIZE OF LOT EXISTING BLDG. (r 1 certify that in the performance of the work for which this 0 permit is issued, I shall not employ any person in any manner J IdOWNER n so as to become subject to the Workers' Compensation Laws. IL �S' OCCUPANCY GROUP W DD SS 40 a Date Applicant s-. 1 CD NOTICE TO APPLICANT: If, after making this Certificate of CITY [y�jJ 1 ITvo. 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 INSPECTIONEl deemed revoked. C] No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ 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 PARKING. effect. SPACES REQ'O D PROVIDED O License Number Lic.Class 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. OF INSPECTOR'S acting In my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES .-NATURE iness and Professions Code). P NT USE OF BUILDING FINAL APPROVAL i Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING B LDINGS 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 I, as owner of the property, will do the work and the # 0-0 0 0 88 structure is not intended or offered for sale (Section 7044, Business and Professions Code). P POSED USE OF BUILDING 0 D o 0 0 0 0 CONSTRUCTION LENDING AGENCY U Mr-fJ O Q,O 3—8 6 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 ISSUANCE FEE above information is correct.I agree to comply with all County ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter UP0316e above-mentioned property for ' jpec ' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 3�3/ tgnat Vre of Per rriiotree Date WORKERS'COMPENSATIONDECLARATION 75M444 t CE 875 (2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insdtie, or a certificate of Workers'Compensation Insurance,or I a cbrtdfied copy thereof(Sec.3800,Lab.C.) Policy No. Company I FOR APPLICANTTO FILL IN ADDRESS ITb�r l I fvV ❑ Certified copy is hereby furnished. Bu ING — 1� LOCALITY DDREss - �? ❑ Certified copy is filed with the county building inspection NEAREST department. i LOCALITY L Iv LE CROSS ST. �AS �un S rJR Date Applicant NEAREST ll++ 7v DISTRICT NO. GROUP TYPE PROC SSED BY ' CROSS ST. �V A CONST CERTIFICATE OF EXEMPTION FROM WORKERS' ( LEGAL COMPENSATION INSURANCE- DESCRIPTION LOT NO. BLOCK MAP HIGHWAY >. NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved I TRACT NOW ON LOT BL.DGS. USE ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE OF 7 V l I certify that in the-performance of the work for which this SIZE OF LOT EXISTING BLDG., permit is issued, I shall not employ any person in any manner I NER I (., so as to become subject to the Workers'Compensation Laws. MAIL OCCUPANCY GROUP ® U ADDRESS \ I Q Date Applicant DAIDkim-em NOTICE TO APPLICANT: If, after making this Certificate of ; �TY LRtAeA NO. OCCUPANT LOAD � Exemption, you should become'subject to the Workers' I Compensation APPLICATION FOR EXIT HARDWARE: p provisions of the Labor Code, you must forth- � a - with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION C1 I No Spec. Knowj. 0 deemed revoked. ❑ OCCUPANCY INSPECTION Panic Devices LICENSED CONTRACTORS DECLARATION � � , I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q. (LIST ITEMS BELOW) I 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 A Kant'S 'Name 1�1J(� U (J P+� PARKINGREO'D. effect. PROViD ED � SPACES License Number Lic.Class I Roe r. I Lam: ei UO�g i LIMITED TIME USE Contractor Date I DATE DATE ElFROM: TO: I am exempt from the licensing requirements as I am a Phone licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my .professional capacity (Section 7051, Bus- I E=XISTING BLDG. STORIES SIGNATURE iness and Professions Code). FI A' APPROVAL SENT USE OF BUILDING I \ ►1!�/ c�C;l``7 V7 `J � ✓, I p ;,-�� Lic.or Reg.No. Date. if G��7V,1 C� 'v C� Y .7 I • NO.OF EXISTING BUILDINGS `!.'_ '�L•�� a ��"� -t� �•''�C, (�' '✓ HOME OWNER-BUILDER DECLARATION ON LOT AND USE nn I hereby affirm that- I am exempt from the Contractor's i License Law for the following reason (Section 7031.5, Busi- � 1- f ness and Professions Code): NO.PARKING {,#('J SPACES PROVIDED , I O O O D 4 0 ❑ I, as owner of,the property, will do the work and the structure is not intended or offered for sale (SectionI D o D o D D o U; 7044,Business and Professions Code). pR, POSED USE OF BUILDINGI y U w o�&TSAw6 0 8 0 8-8 0 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(Sec.3097,Civ.C.). Lender's Name PROPOSED MAX;. OCC. Lender's Address PERMIT FEE i 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 upon the above-mentioned property for inspection purposes. SEE REVERSE -OR EXPLANATORY LANGUAGE Signature of Permittee Date iI -WORKERS'COMPENSATION DECLARATION i 75M444 CE 875(2-s0) MISCELLANEOUS APPLICATION . 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'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) I Policy Nb.. Company FOR APPLICANT TO FILL IN BUILDING...... J7 / L_'1L T _, AZ, vT� ❑ Certified copy is hereby furnished. I BuILDING N Tem le City Blvd LOCALITY - . ❑ ' I ADDRESS 593 • p y , I �. Certified copy is filed with the county building inspections NEAREST department. LOCALITY GROSS ST. y��•� .� Date Applicant RAREST Temple • `DISTRICT.ry O. OUP TYPE PROC SEED BY CROSS ST. Las Tunas Blvd. ; �( CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ! J COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY } o. ( � (CIRCLE) STATE MAJOR SECOND LOCAL IL (Th1S SCCtIOn need. not be completed if the work involved TRACT NO. OF BLDGS. O IAL CONDITIONS NOpv ON LOT IZONE SPECV by the permit is for one hundred dollars ($100) or less. USE OF SE ?i SIZE OF LOT EXISTING BLDG. , I certify that in the performance of the work for which thi's owNER C.H. Mahaffey f e 0 permit-is issued, I shall not employ any person in any manner y so as to become subject to the Workers' Compensation Law's: AIL 1 OCCUPANCY GROUP /1'� W ' ADDRESS I _ •LJ N Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of CITY Alhambra rTio"' 284-4048 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 �e P TRAILER USE❑ GEOLOGY INSPECTION No Spec. Knowl. ❑ 11deemed revoked. � ' OCCUPANCY INSPECTION i Panic Devices ❑ LICENSED CONTRACTORS DPCLARATION ❑ I hP�reby affirm that I am licensed under provisions of Chapler SAFETY PERMIT q (LIST ITEMS BELOW) I NO. OF EXITS ❑ 9 ( ommencing with Section 7000)of Division 3 of the Bdgi- { nesiand Professions Code, and my license is in full force and �ARKING eff 't. svac Es REQ'D E= PROVIDED License Number Lic.Class I LIMITED TIME USE Contractor Date I I DATE DATE ❑ t •I. FROM: TO- lam O:Iam 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 mess and Professions Code). i Vacant _ FINAL APPROVAL PRESENT USE OF'BUILD IN6 ( r Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION 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 ❑ 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). _PRoPosED use OF BUILDING Social Club ' 2 3 7,2 A CONSTRUCTION LENDING AGENCY Propose moving Temple City Alan # o o,o o 8 8 I hereby affirm that there is a construction lending a ency I i for the performance of the work for which this26 I o 0 0 0 0 0 OT p per it is N. f • • issued(Sec.3097,Civ.C.). to ibis 3QnqtiQ1Q.Lender's Name PROPOSED MAX. OCC. 2, 1 8'-81 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 C,nunty ISSUANCE FEE I ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter •Q� po/ t-above-mentioned per for insp tion p/uiposes. SEE REVERSE FOR EXPLANATORY LANGUAGE'M Signature of Permittee Date 1 i COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MISCELLANEOUS PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS MP 0508 0308250002 ! BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: NO. OF CONST NEW BU I LD ntG-ADDRM9-- TR: 6561LT: 192 BL: .001 SQ. FT STORIES TYPE OCCUP GROUP 5928 5930 TEMPLE.,CITY BL STRUCTURE: 1 VN U1 TEMP CA 917802010 ASSESSOR NEAREST CROSS STREET: LAS TUNAS DR 8587-019-026 EXIST BLDG USE: THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY EXIST OCC GRP: USE ZONE: ISSUED PROCESSED S 0 . NOW ON LOT: 09/11/03 JK 03/09/04 OWNER: TEL. 25,258 FINAL DATE FINAL BY: CODE: MAHAFEY HERBERT L;JOANNE K TRUSTEES (626) 447-4740- LIST TMS: 2120 LOUISE AV 16 -7 - 03 i�';r ARCD 910064658 DESCRIPTION FACADE IMPROVEMENT PROJ:2 61X7' TRASH ENCLOSURES, AWNINGS, OCCUP LOAD EXIST: TILE ROOF APPLICANT: OCCUP LOAD NEW: BRETT KING (626) 336-2231- 15809 BLACKWOOD ST PARKING SPACES REQUIRED: SPECIAL-CONDITIONS: LA PUENTE PARKING SPACES PROVIDED: CONTRACTOR: TEL. N0: EXIT HARDWARE: LIMITED TIME USE B G KING (626) 862-8453- NBR OF EXITS: FROM TO 15809 BLACKWOOD STREET LIC. NO LA PUENTE, CA 91744 oq (07(o798861 F D D � FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: APPROV S DATE INSPECT R S GN TURE ARCHITECT R ENGINEERi TEL. N0: LER - OA PERMIT ISSUANCE 27.75 USE LIC. NO: 01 R/M OCC/USE INSPECT 145.95 SAFETY PERMIT TOTAL FEES 173.70 TEMP. ST CT. P 0 ED MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: TEMP. STRUCT. REMOVED 0. OF FAMILIES: D L NG I S: APT/COND. STAT C A S: NO SCHOOLI HAZARDOUS AIR QUALITY: 1000 FEET MATERIALS NO NO NO REQUIRED TOTAL SETBACK FROM 5X I Sr— SET BACK YARD: HWY: PROP LINE: WIDTH: FRONT PL- SIDE PL- Q-/7-a -c o as R;.--c.,-r,,Dar -• -rL_A REPORT ID: OPR267 ROUTE TO: BS0508 1 : WORKERS'COMPENNA1KJN 1XnLLAKA11UN 20-00e3DPW.2/90 I hereby'affirm that I have a certificate of consent t self COUNTY OF LOS'A 1VGELES i = BUILDING•.AND SAFETY DIVISION �• - "* { Ir msum or a certificate of-Workers'Compensation IasuranIle,or i a certified copy thereof(Seg. 3800, Lab.Q-' -- Policy IVo Company i FOR APPLICANT TO FILL IN BUILDING ' R fBUILDIN;G ADD ESS ADDRESS Certified copy,is hereby:furnished g --- LocALlrr ' Certified copy is filed with the county building inspeption Y tP t�•�� ' I department. 9 I�d�+ NEAREST ' o_ CROSS ST. ! Date "� = Applicant SIZE OF L07 NO.OF BCDGS.NOW ON LOT DIS_TRICT NO. GROUP TYPE PROCESSED BY >" CERT KATE OF EXEMPTION FROM WORKERS, CONST. 1`" I - •COMPENSATION INSURANCE i TRACT BLOCK LOT NO. MAP 141C.MWAr NO. (CIRCLCI STATE MAJOR SECOND LOCAL.. {This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL q' by the permit is for one hundred dollars ($100) or less.) USE ZONE SPECIAL CONDITIONS (� I certify that in the performance•of the work for which this 1 ..T, TEL NO. { permit is issued:I shall not employ any person in any manner �'` 41r so as to become subject to the Workers' Compensation Laws. DDRESS q / p �� C OCCUPANCY GROUP v3 1 Date Applicant . CI 14 .4 ZIP Z NOTICE TO APPLICANT: If; after making this Certificate �l OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR Compensation provisions of the-1,6or Code,you must forthwith EXIT HARDWARE: comply with such provisions or`this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION El' revoked. No Spec KnoWl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chipter _ SAFETY PERMIT❑ (LIST ITEMS BELOW) 1 .OF EXITS and Professions Code,and my license is in full force and effect. Name- O us esIs •F i License Number Lic.Class PARKING: REG•D I r��» PROVIDED L= 1 ( Contractor Date I— LIMITED TIME USE i ❑ 1 am exempt from the licensing requirements as I am a DATE DATE licensed architect or a registered professional engineer FROM: TO, 1 acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S and Professions Cade). EXISTING BLDG. STQRIE* / SIGNATURE. Lia or Reg.Na •- DaLe PRESENT USE OF BUILDING FINAL APPROVAL HOME OWNER-BUILDER DECLARATION No.OF A(ND USEBUILDINGS ON LOT I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5. Business and 1 i Professions Code): NO.PARKING SPACES PROVIDED L as owner of the property, will do the work and the structure is not intended or offered for sale(Section 7044,1 PROPOSED USE OF BUILDING Business and Professions Cade). 1 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 , 1 (SCG 3097,Civ.C.). PROPOSED MAX.OCG Lender's Name Fj _ TEL NO. . '+S' a 1Lender's Address AD _ 1 j 1 certify that I have read this application and state that the i .4 ID tt:mew C. above information is correct. I agree to comply with all County PERMIT FEE i r { ordinances and State laws vela to building construction,and ~. { hereby a represen ti s of this County to enter upon ISSUANCE FEE the vc-men ned p er for iniZection purposes. • ?•.r - TOTAL FEE '- g SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pennittee Date