HomeMy Public PortalAbout5478 BARELA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
c CE B75 (11-B4) MISCELLANEOUS APPLICATION {�
I hereby afftm that I have a certificate of consent to self' COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION LI
fnsuro or a certificate of Workers Compensation Insurance,or
a cart{flad copy thereof(Sec. 3800,Lab.C.). ' All
Policy No. CompaAD DRny FOR APPLICANT TO FILL IN BUILDING
❑ Certified Copy Is hereby furnished- ■U1LD1NG 411 O A/ a (�v� LOCALITY
ADDRESS 7 a �7 �1
Bencopy is ailed With the county building inspection C,71
rf /Y �, tIM
NEAR[{T
LOCALITY / /C / �.,{' R
J F� i I CRO/f {T.
Date Applic nt N[wR[/T �/ A DI■ CT O 6 OUP TYPE PR ■S[D ■Y
OROf■ ■T. / > CON/T.
CERTIFICATE OF F7ETTON FROM WORKERS' L[GAL "`
COMPENSATION INSURANCE D[■CRIPTION
LOT P40 I BLOCK Ywr HM4WAY
NO. (CIRCL/) STATE MAJOR C ND LOCAL
//����,,�� NO. OF BLDG{.
ClIds section need not be COmppfeted If the Work involved TRACT NOW ON LOT U TON[ {P[CIAL CONDITION•
by the permtt L for one hundred doD=rs (;100) or lea) USE
of
BIZ[ OF LOT !.2 3-Sg A�O [XISTING_[LDC.. }
I certify that In the performance of the Work for Which this C3
permit is issued,I shall not employ any person in any mannero.N[R p `r'
so as to become subject to the Workers Compensation Laws MAIL T OCCUPANCY dRQU
ADDR E/■
FP
Date Applicant
46
NOTICE TO APPLICANT: If, afterrEL. L`I
making this Certificate of crrYs' _ No.�� _aS(o., y(7 OCCUPANT LOAD a
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 &bAII be TRAIL[R USE ❑ GEOLOINSPUCTION ElNo Spec. Knowl.
deemad revoked.
LICENSED CONTRAC'T'ORS DECLARATION OCCUPANCY INSPECTIONN1*1 Panic Devices
I hereby affirm that I am licensed under pmvidons of Chapter
9 (commencing With Section 7000) of Dfivvon 3 of the Buss SAFETY P[RMrr ❑ (LIST IT[MS BELOW)
iW
NO. OF EXITS
nan and Professions Code, and my license Is in full force and1• O/ 3 �i
PARKINC. PROVID[D
SPACES
License Number Lia Clam
LIMITED TIME USE
Contractor Date DAT= DAT=
I am exempt from the licensing requirements as I am a rRDNI TDI
licensed architoct or a registered profbsdonal engineer ■a[ OF NO. OF ! INS cTOR',
acting In my professional Capacity (Section 7051, Bus' [xISTINC. BLDG. f pp,S ST ORI[■ I ���111 6I TUR[
lnanand ProfossionsCode). FINAL APPROVAL /'
Lia or Reg.No. DatD 7PR[IE NT US[ OF BUILD INC.
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND U/[ �0 2 a 7 l4
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Bud- j • . • (I 3 0
Desi and Professions Code): No. PARKING 2
5'0
El I, as owner of the property, will do the work and the sawc[S PROVIDED �7
structure Is not intended or offered for sale (Sectio •
n
7044,Business and Professions Code). o • 8 11`8 0 265
CONSTRUCTION LENDING AGENCY PROPOSED U/[ OF ■UILDINC.
I hereby sffiffi that there is a construction lending agency
for the performance of the work for which this permit is \� =
issued(Sec. 3097,Civ.C.).
'c
Loader's Name
/J/n, 3 PRorof[D MAX. GCC.
Lender's Address
PERMIT Else
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSU,aNCE Fes
ordinances and State laws relating to buil construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upone a ve-m tioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Data