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WORKERS COMPENSATION DFC LA RATION 78M444
CE 876(2 80) MISCELLANEOUS APPLICATION
I hereby affirm
cert that 1 have a cr.rrlmpen of consent to Belt COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Workers Compensation ion Insurance or
a certified o 6 of(Sec 3800 Lab C)
Policy No " � Company state Fund EUILDIna
FOR APPLICANT TO FILL IN ADDRE..
❑ Certified copy is hereby furnished uuOmc 4303 Temple Cit Blvd. LOCALITY 000(
Certified co DDweas
py a flied with the county budding inspection ST
uuCROSS
department Lo
rr Roas ar
Date Applicant "CAR
a" Lover AEI18a DISTRICT O a CUP coneT w HY
Ross ST
CERTII ICATL OF EXEMPTION PROM WORKERS LCCAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO BLOCK
XOR . (CIRCLC) .TATE MAJO aECONO LOCAL a
NO
(This section need not be coli) le[ed If the work Involved TRACT NO OF OLOa9 USE ZONE aRBCIAL CONDITIONS Q
N ON LOT
by the permit Is for one hundred dollars (SI00) or less) USE o. U
E OF LOT It"a
TING BLDG
I certify That m the performena of the work for which this a
permit Is Issued, 1 shall not employ any person in any manner "ER Southern Pacific Railroad f-
so as to become subject to the Workers Compensation Laws I.VAIL OCCUPANCY GROUP �/�s _ w
ORHss f'
a
Date Applicant N
NOTICE TO APPLICANT If after making this Certificate of ITP NOL OCCUPANT LOAD Z
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 NJo Qr.` Knowl Eldeemed resoked P
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
1 hereby affirm that I am hLensed under provisions of Chapter SAFHTY PERMIT q (LIST ITEMS BELOW) NO or EXITS
9 (commencing with Section 7000) of DIr¢ion 3 of the Bust
ass and Professions Code and my license is in full force and
PARKIN RINa
, �fect
SPACE. "e0 D O PRovIOED
License Number Lm Class
V LIMITED TIME USE
Contractor. Date - DATR RATS
❑ I am exempt from the licensing requirements as 1 am a
IicensLd architect or a registered professional engineer SIZE or NO OF INSPECTOR a
acting In my professional capacity (Section 7051 Bus- EXISTING BLDG .TORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL
89ENT y98 OF BUILDING pallet Mfg.
Lic or RLg No Date-
HOMEOWNER
ateHOMLOWNER BUILDER DECLARATION "o of EXISTING USE BUILDINGS
ONO
Lar AND uac
I hereby affirm that I am exempt from the Contractors IOAfI
License Law for the following reason (Section 7071 5 Bust
ness and Professions Code) NO PARR
SPA PROVIDED❑ ;?071 C A 1 as owner of the property will do the Work end the
structure Is not intended or offered for sale (Section
t
7044 Business and Professions Code) NROPo98D u.E of eu uolnc vholdsale lumber �,—
CONSTRUCTION LENDING AGENCY Bales
I hereby affirm that there Is a construction lending agent)
for the performance of thL work for which this permit Is
issued(Sec 3097 Civ C )
Lender s Name
PROPOSED MAX OCC ,
Lender's Address PERMIT PEE '
I certify that 1 have read this application and state that the
above Information Is correct 1 agree to comply with all County ISSUANCE PEE ,
ordinances and State laws relating to budding construction TOTAL FEE
and hereby authorize representatives of this County to enter
on wove mentioned p�pert m ctwn SEE REVERSL I OR EXPLANATORY LANGUAGE
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Sitgnatur0rof Permittee Date