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Home My Public Portal About5946-5946 1/2 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) M ISCELLANEOUS APPLICATION 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 certified copy�lip.ee04�Sec.3800,Lab.Q. / Polic} No b 9y ompany FOR APPLICANT TO FILL IN BUILDING tjf ADDRESS �J a FlCertified copy is hereby furnished. BUILDIN SS t LOCALITY ,t ADORE e� Certified copy is filed with the county building inspection Y LOCALIT /p �" NEAREST department. �P� 1 C� C,�-� CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P CESSED BY CROSS ST. /N�I'J� �rlll� �Op 2 CO NST .J CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL le AV �/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLOGS. (This section need not be completed if the work involved TRACT NOW ON LOTUSE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of //!J I certify that in the performance of the work for which this SIZE OF LOT �.L EXISTING BLDG. f� � o permit is issued, I shall not employ any person in any manner OWNER b.� OLS'Witt(f V1ar�2S' —9ClC ,So [zi] so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADDRESS ~ Date Applicant 63iia_ ri e- VI/ ve_' z; NOTICE TO APPLICANT: If, after making this Certificate of cITY lC;-6w NO. MT—_ 1V,6 Z OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- APIfLICATION 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 and a4us i N eSS effect. PARKING REQ'D D PROVIDED SPACES License Number Lic. Class 4! ree.� // Zv S-E LIMITED TIME USE Contractor Date DATE DATE ElI 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 N'fTURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). J /a FINAL APPROVAL PRESENT USE OF BUILDING t Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ^r� I hereby affirm that I am exempt from the Contractor's ON LOT AND USE License Law for the following reason (Section 7031.5, BusiTcJ�i �y ness and Professions Code): NO. PARKING SPACES PROVIDED I, as owner of the property, will do the work and the a «I III 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 G'a 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 TOTAi-FEE upo the above-me tioned property for insp ction purposes. Zb/93 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION " ;76W!444 M ISCELLANEOlJS:APPLICATION I hereby affirm that I have a certificate of consent tself CE 875(11-84)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 ADDRESS 6-/ FlCertified copy is hereby furnished. BUILDING00 PCE LOCALITY ADDRESS T ElCertified copy is filed with the county building inspection LOCALITY NEAREST department. CRGSs ST. Date Applicant NEAREST DISTRIC��iii NO/y GR UP ITYPEV P CESSED By CROSS ST. D�/-' CONSTCERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. OF NO.. (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT S. USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOVICT EXISTING BLDG. ' a 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 N • y so as to become subject to the Workers'Compensation Laws. MAIL [glUr` 'OCCUPANCY GROUP o ADDRESS S f4k fp 3 /6 TRE , Date Applicant 221 !:3 I,J NOTICE TO APPLICANT: If, after making this Certificate of CITY L' o NO. - a (Ij OCCUPANT LOAD z Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: K Compensation provisions of the Labor Code,you must forth- ❑ with comply with such provisions oI this permit shall be TRAILER USE GEOLOGY INSPECTION❑ No•Spec. Knowl. deemed revoked. I Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM[ (LIST ITEMS-BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS nese"and•Professions Code,and my license is in full force and y�j��/�p/�� W. V 1 effect. T + PARKING REQ'D PROVIDED SPAiCES License Number I Lie. Class �� '� i LIMITED TIME USE Contractor Date 1 DATE GATE El am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO.OF [HSPS CTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES III SIGNATURE iness and Piofessions Code). FINAL APPROVAL p PRESENT USE OF BUILDING Lic.or Reg.No. Date I P 0- 2d/rr t-e—PO GJ,✓ -- L! E HOME OWNER-BUILDER DECLARATION NO. OF XISTING BUILDINGS " ON LOT AND USE I hereby affirm that I am exempt from the Contractor's �J - -1� 1! License Law for the following reason (Section 7031.5, Busi- /1_ �,:alt--ULi'IS ness and Professions Code): NO. PARKING /. � `R' - 1'{r' (II .+1= I, as owner of the property, will do the work and the SPACES PROVIDED i''��- 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 is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building Construction, L and hereby authorize representatives of this County to enter TOTAL FEE 7 upon ove-mentioned property for inspectinpurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P�ee Date 1 I AW1tKERS'CObiPENSATIONDECLARATION CE 8754(11-84) MISCELLANEOUS APPLICATION 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 certified copy thereof(Sec. 3800,Lab.Q. /A Policy No. Company FOR APPLICANT TO FILL IN pDDRE3S ��6 1/2, F - . 'lati!-t/v'/ Certified copy is hereby furnished. foTILDING Cp Alla ..� GP `� LOCALITY , ADDRESS J �iampke— ElCertified copy is filed with the county building inspectionOCALITY '� NEAREST department. Ci ►7� CROSS ST. Date Applicant EAREST DISTRICT N GR P TYPE PROCE F,17 LJ CROSS ST. "SP Iut_('CLSP CONST. V ' �• L� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHW AY STATE MAJOR SECOND OCAL NO. (CIRCI.Q) 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 (5100) or less.) SIZE OF LOT EXISTING BLDG.LI, OF a 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 owNERS' so as to become subject to the Workers' Compensation Laws. �j Q/� OCCUPANCY GROUP AD OR ESS v0�•�Q�, �� C 1 VV O Date Applicanteo e u�J NOTICE TO APPLICANT: If,after making this Certificate of CITY`TNo. ;2$S --11 N2 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 Panic Devices El 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. PARKING SPACES REO'D PROVIDED F License Number Lie. 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- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lie.or Reg.No. Date _ /,aza HOME OWNER-BUILDER DECLARATION OF EXISTING BUILDINGS ON LOT AND USE One. 1 Sri I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- C--.Z Id'SrL. ness and Professions Code): NO. PARKING y El I, as owner of the property, will do the work and the SPACES PROVIDED A �N s S structure is not intended or offered for sale (Section .551 IL8 A 7044,Business and Professions Code). P OPOSED USE OF BUILDING # 0 0 0 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency ; plJ�t � o o D O O D D for the performance of the work for which this permit is 4 issued(Sec.3097,Civ.Q. � � D� 0 729-86 Lender's Name 1 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 buildi construction, and hereby authorize representatives of this, ounty to enter TOTAL FEE upyh the above-mentioned property for inspe tion purposes. ,A-3SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee ate W,_Vv ERS'COMPENSATION DECLARATION CE 875(2-80) W SC E L LA N EO U S APPLICATION inhereby 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.) Policy No. Company BUILDING FOR APPLICANT TO FILL IN ADDRESS F1Certified copy is hereby furnished. Loo BUILDING A DRES �� „ ��lZ ��/ ��e I • LOCALITY ❑ Certified copy is filed with the county building inspection r NEAREST department. �-O- LITY CROSS ST. Date Applicant REST ]� 4 E DISTRTjj4f.. GRCJ� TYP / PROCE ED B OSS ST.LI• -5 A 1! I//AO/ I/VLi CONS eV CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �•/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAPHIGHWAY } NO. (CIRCLE) STATE MAJOR SECAD LOCAL O. NO. OF BLDG S. (Tills 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 ($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 WNER' h9121 5 C 50P 1-- so as to become subject to the Workers' Compensation Laws. A IL g /� OCCUPANCY GROUP 0 LU Date Applicant Z ` d:5 /i• e CL NOTICE TO APPLICANT: If, after making this Certificate of 7-FAke e ei T No-,�,F7 °J 7.9 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 or this permit shall-be TRAILER USE❑ GEOLOGY INSPECTION NO Spec. KnOWI. ❑ deemed revoked. Panic DeVIC@S ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 1--I (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 REO'D D PROVIDED O License Number Lic.Class LIMITED TIME USE Contractor Date GATE 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 SIGNATURE iness and Professions Code). R NFINAL APPROVAL PT USE OF BUILDING Lic.or Reg.No. Date T1Ar /If�4gi,r,?&Ptd Ui/4j%r/P sllj L NO.OF EXISTING BUILDIN s HOME OWNER-BUILDER DECLARATION ON LOT AND USE I hereby affirm that I am exempt from the Contractor's 2 5 9,7 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING # O O O O $$ SPACES PROVIDED ❑ I, as owner of the property, will do the work and the o o o 0 0 0 0 12 structure is not intended or offered for sale (Section 7044, Business and Professions Code). OPOSED USE OF BUILDING 0 a06-85 CONSTRUCTION LENDING AGENCY 1� ,r1 - Rl I hereby affirm that there is a construction lending agency iJ 0 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. O Lender's Address PERMIT FEE 1 certify that I have read this application and state that the ll V S above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE 4 I and hereby authorize representatives of this County to enter U up the above-mentioned property for inspe�ct' purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �-0�' r�, ✓g~2 r8'i_ Signatur f Pb ermittee Date WORKERS'COMPENSATION DECLARATION CE 76M444 �A N ®@�S APPLICATION I hereby affirm that 1 have certificate of consent to self COUNTY OF LOS ANGELES j 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 ADDRESS ❑ Certified copy is hereby furnished. BADDRESS ,.` .p,v A� LOCALITY ❑ U DD 6C Certified copy is filed with the county building inspection ,NEAREST department. I LOCALITY icRoss sr. Date Applicant NJMREST DISTRICT NO. GROUP TYPEr,7_."D .BY to ROSS ST: UJl)OORM CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL CONST.v COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCKI.M Ap HIGHWAY STATE MAJOR SECOND LOCAL NO. OF SLOGS. ,N O. ' (c IR.c LE) d (This section need not be completed if the Work involved TRACT NOW ON.LOT i SE ZONE SPECIAL CONDITIONS 0 by the permit is for one hundred dollars ($100) or less.) V• USE OF SIZE OF LOT EXISTING BLDG. i O I certify that in the performance-of the work for which this /� n �l ' permit is issued, I subject to employ any person in any manner NER 1...fttuz 7A�DIY. U so as to become subject to the Workers'Compensation Laws. OCCUPANCY GROUP tL IL , n ADDRESS' P-0- 'v I a Date Applicant to Z. NOTICE TO APPLICANT: If, after making this Certificate of clTv II—LVAM Ct.t TE-L-287-,77,7.3 I 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 deemed revoked. ❑ ❑ No Spec. Knowl. ElLICENSED 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 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code;and my license is in full force and effect. PARKING SPACES REq'D PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date ' DATE DATE �-T FROM: TO: ' L_1 I am exempt from the licensing requirements as I am a, licensed architect or a' registered professional engineer SIZE OF NO. OF INSPECTOR'S actin in m professional capacity, EXISTING BLDG. STORIES " g q p p y,(Section 7051, BUS- SIGNATURE- -C-2 IG NATUR E- �► iness and Professions Code). I ! I ! FINAL APPROVAL I( 1 r• PR NT USE OF BUILDING I � .r .c Lic.or Reg.No. Date Iw,'i /C dtIsv 9 �, HOME OWNER-BUILDER DECLARATION' NO.OF EXISTING BUILDINGS _-k821 A ON LOT AND USE , I hereby affirm that, I am exempt from the -Contractor's # o'0;0 0 8'8 License Law for the following reason (Section 7031.5, Busi- ;i o o(o 0 0 0 o z ness and Professions Code): No,.PARKING, SPACES PROVIDED •i 0,7, 1. 9,-84 + El I, as owner of the property, will do the work and the 1 structure is not intended or offered for sale (Section 7044,.Business and Professions Code). WWSPOSED USE OF BUILDING I I CONSTRUCTION LENDING AGENCY D I I hereby affirm that there is a construction lending agency' T TNe Nsrwr myI! for the performance.of the work for which this permit is' issued(Sec.3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. I (II .Lender's.Address PERMIT FEE l 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, 5 and hereby authorize representatives of this County to enter TOTAL FEE —5",In® uP th above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ,, WQRKER$'COMPENSATION DECLARATION CE 875(11-841 MISCELLANEOUS APPLICATION I rebaffirm 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 certift, d copy thereof(Sec.3800,Lab.C.). Policy-No. Company FOR APP LI CANT TO FILL IN BUILDING �7 ADDRESS r e-f Certified copy is hereby furnished. BUILDINLt(PG ADDRESS _5C1r 1. e LOCALITY Certified copy is filed with the county building inspection LOCALITYy %J NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT OGI;}Up TYPE P CESSE CROSS ST. (/A/J CONST. D BY CERTIFIQATE 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. 17- a I certify that in the performance of the work for which this C3 - permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. rs, / OCCUPANCY GROUP - Date Applicant ADDRESS ✓ ✓C �jl��(• W TEL. OCCUPANT LOAD °- NOTICE TO APPLICANT: If,after making this Certificate of CITY -(,yVl. No. s 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 oI this permit shall be TRAILER USEGEOLOGY INSPECTION 1:1deemed revoked. El ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM T ❑ (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 C effect. 4+.� PARKING R6q D � PROVIDED SPACES License Number Lic. Class I LA P htk"+C'V' LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF FROM: TO: INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVALd� Lic.or Reg.No. Date 4 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS siy * y P;1Y�yL 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 1 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). /J CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING yJ. 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 Tcertify 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 ordinanc2wm=roperty State laws relating to building construction, d lierehorlZe representatives of this County to enter TOTAL FEE Q(� i} n the for inspection purposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE Signature q Permittee Date i I WORKERS'COMPENSATION DECLARATION CE 875(11-84) M ISCELLANEOUS APPLICATION I I hereby affirm that i have a certificate of consent to self COUNTF LOS ANGELES BUILDING AND SAFETY DIVISION ,. insure, or a certificate of Workers'Compensation insurance,or 'fl— I a certified copy thereof(Sec.3800,Lab.C.). S' Policy No. Company FOR APPLI NT TO FILL IN wooeess FiCertified copy is hereby furnished. /+,g BUILDING LOCALITY ADDRE35 i } Certified copy is filed with the county building inspection g LOCALITYNEAREST ' department. ' — e CRDss sT. Date Applicant NEAREST DISTRICT NO. G� P TYPF-CONS / ESSED BY CROSS ST. ,,^`('') l/'/ I CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSL RaNCE I DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLET NO. OF BLOCS. (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 (5100) 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 +rg OWNER r so as to become subject to the Workers' Compensation Laws.1 MAIL ,� _ I � OCCUPANCY GROUP ADDRESS T �,QP. •) Date .-Applicant � " NOTICE TO APPLICANT: If, after making this Certificate of g CITY - -�. �� To� OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATI N FOR EXIT HARDWARE: — Compensation provisions of the Labor Code, you;must forth- } with comply' with such Provisions or this pen.hit shall be TRAILER USE n GEOLOGY INSPECTION L.r NO Spec. KnOWI. deemed revoked. , OCCUPANCY INSPECTION LS Panic Devices ❑ LICENSED CONTRACTORS DECLAII—kiION 01 I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT LIST ITEMS BELOW)9 (commencine with Section 7000) of Division 3lof the Busi- NO. OF EXITS ness and Professions Code.and my license is in ft ll force and effect. L v PARKING REO•D PROVIDED SPACES o I License Number Lie. Class I LIMITED TIME USE y Contractor Date DATE DATE FROM: TO: n ) ❑ I am exempt from -he licensing requirements as I :,in a INSPECTOR'S a licensed architect or a registered professional angineer SIZE OF NO. OF SIG ATURE ? acting in my professional capacity (SectioIil 051. Bus- EXIST:NG BLDG. STORIES -:6 iness and Professions Code). F I N A PP OVAL 010 1 PRESENT USE OF BUILDING U Lie.or Reg.No. Date.I Iuv HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ('� /�� W'M—CUME 10 A„"d ON LOT AND USE I Hereby affirm that I am exempt from the Contractor's i License Law for the following reason tSection 7031.S. 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 ;i-le (Section T 7044.Business and Professions Code). CONSTRUCTION LENDING AGENCY` � PROPOSED USE OF BUILDING 1 I hereby affirm that there is a construction lending agency T I for the performance of the work for which this permit is � issued(Sec.3097,Civ.C.). Lender's Name 7 PROPOSED MAX. OCC. Lender's Address 25.00 I - PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply wi-.h all County ISSUANCE FEE ordinances and State lags relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25.00 T 'r up lie above- entioned property for inspection purposes. �!(I; � /� SEE REVERSE FOR EXPLANATORY LANGUAGE Sienature of Permittee g Date