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Home My Public Portal About5938 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 I hereby affirm that I have certificate of consent to self CE 875 (2-80) MISCELLANEOUS APPLICATION COUN'T'Y 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 BUILDING �/E— ADDRESS a7 ❑ Certified copy is hereby furnished. BUILDING .7y /y9 LOCALITY e / F1Certified /g M / I Certified copy is filed with the county building inspectionNEAREST department. LOCALITY T/�• CROSS ST. Date Applicant 0141MAREST Tjgn/j n DISTRICT NO. GR UP IT M7 SPR SSED BY CROSS ST. ` 4(.w�t7 CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP IGHWAY No. >� (elReLe) (This section need not be completedN STATE M JOR SECOND LOCAL } if the work involved NO. OF BLDGS. USE ZONE SP GIAL CONDITIONS TRACT OW ON LOT V by the permit is for one hundred dollars ($100) or less.) USE OF U r'' I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. CC� permit is issued, 1 shall not employ any person in any manner WNER 23�/' a,ru Dom_ so as to become subject to the Workers' Compensation Laws. AAIL.RESSGI /C�� r OCCUPANCY GROUP I I V LU Date Applicant0. 00, TEL. cn NOTICE TO APPLICANT: If, after making this Certificate of CITY-r m NO. '-�� OCCUPANT LOAD Exemption, you should become subject the Workers' APP CATION 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 N ❑ deemed revoked. ❑ No Spec. KnOW(. ❑ II LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I herel7y 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 •Id Professions Code, and my license is in full force and IPARKINe. effect REQ'D PROVIDED SPACES • 1� License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as 1 am a. FROM: TO: licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EX!,,4TING BLDG. STORIES SIGNATURE iness and Professions Code). PR ESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date --�+`F .� S r� I_J HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS Hes< 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, 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). OPOSED USE OF BUILDING ! d 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. OCG. Lender's Address PERMIT FEE I certify that 1 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 C my to enter 74& above-mentioned property or insp tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 876(2-80) MISCELLANEOUS A P P L I CAT 10 N I hereby affirm that I have certificate of consent to self COUN'T'Y 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.) 11 Policy No. Company FOR APPLICANT TO FILL IN BUILDING � }� ADDRESS J ❑ Certified copy is hereby furnished. UILDING C ® dD [ LOCALITY Certified co A DRESS copy is filed with the county building inspection NEAREST department. LOCALITY C_ CROSS ST. Lr/J/ f Date Applicant NEAREST DISTRICT NO UP TYPEPROC SSED BY CROSS ST. �/(�it� COIV�Jrf CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL VY COMPENSATION INSURANCE DESCRIPTION LOT NO. �J BLOCK MAP !R!! r HIGHWAY } NO. L/_ (CIRCLE) STATE MAJOR SECOND LOCAL d (This section need not be completed if the Work involved NO. OF LOT USE ZONE SPECIAL CONDITIONS O P TRACT NOW ON LOT by the permit is for one hundred dollars (S100) or less.) USE OF U IZE OF LOT EXISTING BLDG. C�� cc O I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner WNER z H so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP �jZ, W DRESS Y /C, Date Applicant �,` 9 OY1101')c{ °' CO NOTICE TO APPLICANT: If, after making this Certificate of TY N0. 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 NOS Ki ❑ deemed revoked. pec. IIOW. ❑ CT NSP IEION Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY ❑ I hereby affirm that 1 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 PARKING. effect. SPACES ��11 REQ'D PROVIDED 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 SIGNATURE iness and Professions Code). FINAL APPROVAL = ) I RESENT USE OF BUILDING �/u� ! ; �+j�-:•�� Lic.or Reg.No. Date kIS ' ORc E&ctACL42n c.l IIOME OWNER-BUILDER DECLARATION NO.OF ED NG BUILDINGS ON LOT AND SE 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 `• O�' I, as owner of the property, will do the work and the SPACES PROVIDED 3 A structure is not intended or offered for sale (Section i o 0 o o 4 0 7044, Business and Professions Code). PROPOSED USE OF BUILDING 0 0 0 0 0 0 0 CONSTRUCTION LENDING AGENCY ,[� C O I hereby affirm that there is a construction lending agency z> 9 c h t // Pn G 1 _ 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 1 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 1 'nd hereby authorize representatives of this County to enter Son tl ove-mentioned prop ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 9 f� / ` ' T / Signature of P M. ate / WORKERS'COMPENSATION DECLARATION SCE 875(71-8�) M ISCELLANEOUS 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.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING p pODRE95 O M Certified copy is hereby furnished. RE ADDSS �i LOCALITY 0 Certified copy is filed with the county building inspection LOCALITY. NEAREST department. X e C ceoss ST. Date Applicant NEARESTDISTRI T NO G UP ITYPE ESSED BY CROSS ST. A_ 7 NST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NOOF BLDGS. NO. (CIRCLE) . (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. 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 C.-, so as to become subject to the Workers' Compensation Laws. J� MAIL f� OCCUPANCY GROUP ® o Date Applicant ADDRESSPO, ! v /� TELT W NOTICE TO APPLICANT: If,after making this Certificate of Y( CITY aJ1e, G NO. � '� 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❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E] 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. PARKINGREq'D PROVIDED SPACES License Number Lic. Class LAW MAW 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- EXISTING BLDG. STORIES SIG TURF iness and Professions Code). _` � FINAL, APPROVAL, Glf _ZI/_�f� PRESENT USE OF BUILDING —r Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE b I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness usi ness and Professions Code): NO. PARKING SPACES PROVIDED ��' �, ' E;Iy- 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). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING s L� 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. OCG. 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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r Signat of ermitte Date •:, PORi:•SRS'COMPENSATION DECLARATION CE 876(11-84) MISCELLANEOUS APPLICATION I hereby affirm that 1 have a'certificate of consent to self insure, or-a rgztificate of workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION u a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS I ElCertified copy is hereby furnished. BUILDING �' e n a i� / LOCALITY ADDRESS FICertified copy is filed with the county building inspection NEAREST bis department. LOCALITY py„ I s C` CROSS ST. V1� MJ Date Applicant NEAREST `�/}„ 1 DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. b �, S CON57. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF BLOCS. (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 d 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 OWNER �� ' O y so as to become subject to the Workers' Compensation Laws. MAIL /® 7 OCCUPANCY GROUP Ot ADDRESS Date Applicant I„ NOTICE TO APPLICANT: If, after making this Certificate of CITY ` N �a — d OCCUPANT LOAD y Exemption, you should become subject to the Workers' A2 z Compensation provisions of the Labor Code,you must forth- A LICATION FOR -Qp EXIT HARDWARE: _ with comply with such provisions or this permit shall be TRAILER UsE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. Panic Devices I 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 Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and f� effect. V PARKING SPACES Rrm Wo D PROVIDED D License Number Lic. Class �S O Vl Irl 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 OR NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). I D PRESENT USE OF BUILINFINAL APPROVAL G '� Lic.or Reg.No. Date HOMEOWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS [,I'_Is{!I—�fi(J; ;,Li!iCj4:, ON LOT AND USE I hereby affirm that I am exempt from the Contractor's It'd 7-11, 15 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 ��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.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.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 above-mentioned opertyfor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION ' CE 875 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 •.rtified copy thereof(Sec.3800,Lab.C.). UILDING Pocy No. Company FOR APPLICANT TO FILL IN B ADDRESS 3 A F Certified copy is hereby furnished. UILDING LOCALITY NWO ADDRESS Certified copy is filed with the county building inspection L CALITY I AA NEAREST department. I h, Q CROSS ST. Date Applicant NEAREST DISTRICT N GRA TYPE PROCES D BY CROSS ST. Rja"k 0fr//'f NST. 11, CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL HIGHWAY COMPENSATION INSURANCE DNO. (CIRCLE) LOT NO. BLOCK MAP (CIRCLE)CLE) ATE MAJOR SECOND CAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZO E SPECIAL 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 o permit is issued, I shall not employ any person in any manner OWNER g)CP 13LQV' so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o 1--' Date DDR ESS Applicant NOTICE TO APPLICANT: If,after making this Certificate of clrY No�' l Q�3I OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- APPLOCATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USEGE LOGY INSPECTION ❑ deemed revoked. ❑ E] 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 effect. PARKINGREq'D PROVIDED SPACES 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 NATURE acting In my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES S NATURE iness and Professions Code). FINAL APPROVAL w e Lic.or Reg.No. Date PRESENT USE OF BUILDING HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS y®/' 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 da the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 5 13 Q`: A 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING } o o 0 o F 8 I hereby affirm that there is a construction lending agency 0 o D a o 0 0 V, for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. V 1 2 13—b8 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, d hereby authorize representatives of this County to enter To rwi.FEE pon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE yI, Signature of Permittee Date v \\ i WORKERS'COMPENSATION DECLARATION sMaaa MISCELLANEOUS APPLICATION �+ I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING A14D SAFETY DIVISION U insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Seo.3800,Lab.C.). I Policy No. Company FOR APPLICANT TO FILL IN BUILDING f/ ��pg ADDRESS d Cl/ Certified copy is hereby furnished. $ U ILO ING MORES Pij�Yf e CSL LOCALITY ! Certified copy is fried with the county building inspectia LOCALITY NEAREST I department. CROSS ST. Date Applicant NEAREST . / • DIST ICT J�j�O. GR P CONS�/�/ P%RJCrd1ESSED BY CROSS ST. p .0 lJ OY/✓J�fi.� } CERTIFICATE OF E.`C MPTION FROM WORKERS' DESLEGAL CRIPTION LOT NO. I BLOCK COMPENSATION INSURANCE MOP .1 j STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TR^ACT I NOW ON LOT USE ZONE(SPECIAL. CONDITIONS I by the permit is for one hundred dollars (S 100) or less.) ISE OF j e SIZE OF LOT I EXISTING SLOG. I zertify that in the performance 3f the%vork for:vhic this $ permit is issued. I shall not employ any person n any man OWNER �,q� /P�'y1 I ! so as to become subject to the Workers' Compensation LaL OCCUPANCY GROUP I I NAIL 4 I .1DOR=55 t Date applicant NOTICE TO APPLICANT: If,after making this Certificate %! ITS B ' OCCUP4NT_CAO Exemption, you should become subject :o the Worker Compensation provisions of-he Labor Code' you :rust forth- AP.D LICA-iGN FOR O R =XIT iiARCbVARc: Leith comply with such ?rovisions or :his ?er nit shall be 1�TRAIL.R USE — GEOLOGY NSPECT:o;t = Vc SCec. <^o'avi. ! ' deemed;evoked. LICENSED CONTRACTORS DECLARATION I OCCUPANCY :NSPECT:oN Panic Devices i I hereby affrrtit that I am licensed under provisions of C:taDte' SAFETY PERMIT —' LIST ITEMS BELO`N) ' 9 icommencinz with Section 7000) of Division 3 of the Susi- — No. OF EXITS ness and Professions Code,and:ny license is in full force and (� PARKING I —� SPA C. S REOD • I 1 PR ONTO E7 effect. •r. I License Number L.-c. Class , LIMITED TIME USE I Contractor Date li 'LTC '"'E L i R 40•A: TO: CI am exampt from the 'icensin; requirements as I am a licensed architect or 1 :egistered ?rofessionai 9no-in te: Ij_1Z=OF No. OF INS TO actin, in my profession:.) capacity Sac-non -05'. Bus- =X:STING SLOG. STORIES I A' iness and Professions Code). F;NAL APPROVAL PRESENT USE OF 3UILOING - [a Lic.or Reg.No. Date t _ � 1 6 HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS 1 I '7N LOT AND USE I I I hereby affirm that 1 am exempt from :he Contractor's i i License Law for the following :eason (Section -031.5. Bus: 1� ness and Professions Code): !NO. PARKING I [, as owner of the propertf, will do rite work and the �SPACS:S ?ROVIDED - structure is not intended or offered for sale (Section 104•x,Business and Professions Code). ^C CONSTRUCTION LENDING AGENCY %�? oaosED USE OF SUMMING Qhs RAJ I hereby affirm that there is a construction lending agent,: ! i 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 J •. li PERMIT FEE 2'5C.UU 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, I •) and h reby authorize representatives of this County to enter I TOTAL FEE u.00L FEE 25,00 e above-mention d roperty r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE %% -/ Signa ire of D,!:mi:tee Date WORKERS'COMPENSATION DECLARATION I 2000 3DPW12/90 MISCE.LmLANEOUS APPLICATION . I hereby affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES � BUILDING•AND SAFETY DIVISION •ihsure,or a certificate of.Wdr'kers'Compensation Insurance,or A certified copy thereof(See.3800, Lab.C.)' I u i Policy No. Company FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRE '�� ADDRESS H Certified copy,is.hereby:furnished. g 5 LOCALITY Certified copy is filed with the county building inspection CITY ZIP department, ! -ram �� NEAREST CROSS ST. Date `=' Applicant I SIZE OF LOT NO.OF BLOGS.NOW ON IAT DISTRICT No. I GROUP TYPE PROCESSED BY ' CONST. 0 CERTIFICATE OF EXEMPTION FROM WORKERS TRACT BLOCK LOT NO. V I COMPENSATION INSURANCE MAP HIGHWAY (This section need not be completed if the work involved H°' (CIRCLE) STATE MAJOR SECOND LOCAL.. P ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) I.certify that in the performance,of the work for which this IVli�e�y a TEL No. U permit is issued;I shall not employ any person in any manner °� LU I so as to become subject to the Workers' Compensation Laws. ADDRESS .® OCCUPANCY GROUP I Date Applicant , CITY . t'n CA zip �� u F7 Z NOTICE TO APPLICANT: If; after making this Certificate B►+� OCCUPANT LOAD of Exemption. you should become subject to the Workers' 11APPLICATION 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 ❑ I 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 Business ame o 1;15 ess NO.OF EXITS and Professions Code,and my license is in full force and effect. PARKING• D i License Number Lie.Class �J SPACES REQ'D PROVIDED I I Contractor Date LIMITED TIME USE ! El am exempt from the licensing requirements as I am DATE DATE a 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 1 SIGNATURE. Lic,or Reg.NO. - Date PRESENT USE OF BUILDING FINAL APPROVAL 7-01i ' 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, Business and Mpg 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_1 PROPOSED USE OF BUILDING Business and Professions Code). usr��) — I�r,��e D 1 •- i 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.). PROPOSED MAX.OCG Lender's Name APPLIIF41NT)ul �' v� TE N_O �� •• Lender's Address ADDRESS �`IWf,�/� I certify that I have read this application and state that the �'�'a � v ca above information is correct. I agree to comply with all County PERMIT FEE 1rCi p` 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 _ .. ( I••5• IZ TOTAL FEE % 22 SEE REVERSE FOR EXPLANATORY LANGUAGE isil, zure of Per tee Date i I