HomeMy Public PortalAbout9180 BIDWELL ST_Miscellaneous__ woRKERs coMPENSATIONDECLARATION cE eia((11-84) M ISCELLANEOU, APPLICATION
I hereby affirm that I have a certlflcate of consent to soli AUNTY OF LOS ANGELES '. 'BUILDING AND SAFETY DIVISION
huaJro os a certificate of Workers'Comppnsation Ianllance,or
a cert�f7ed copy thereof(Sec. 3800,Lab.Q.
BUILD IN6 /
Policy No. Company FQR,APPLCCANT TQ FILL,IN, wDDRES■
Certified copy Is hereby.fur imhed. BUILDING• p `
ADDRE// O f LOCALITY
❑ Certified copy L filed with the county building bsspecdon NEAREST
LO CA LI'YY CRO// ST. -Lr fTaJ
department. -
Date AppHcantn6ARE■ 1 J \ DI/TRIC? OR TYPE PROCEISED BY
N
CROSS ST. CO
CERTIFICATE OF EXEMPTION FROM WORKERS' LE GAL 5, O �
COMPENSATION INSURANCE DE CRIPTIDN L07 NO. ■LOCK —1 H"�AY STATE MAJOR SECOND LOCAL
RO, (DIR CLi)
no. or BLDGS.
(This Section need not be COiD lased If the work involved T.Ac.4 '•f' ' nor ON LOT USE ZONE ■PECUL CONDrTIONR
by the permit is for one hundred do lar ($100) or lose.) usE or DD -
SIZE OF LOy 3' 3 US TING BLDG.
6, V r
I oarttfy that In the performance of the work for which this
permit Is issued, I rhs.1 not employ any person in any manner o.NER s56'
so as to become subject to the Workers' Compensation Lawn
YA1L {•}(i OCCUPANCY GROUP o
ADORE■
Date Applicant W
SEL. OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certtflcate of am NO
C3.-
. vi
Exemption, you should become subject to the Workers' APPL ATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth
with comply with such provisions or this permit shall be ❑ ❑ No Spec. Knowl.
deemed revoked. of
TRAILER u/E GEOLOGY IN•rEcrloN
LICENSED CONTRACTORS DECLARATION OCCUPANCY IN■PKCTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (comendng with Sdction 70001 of Division 3 of the Susi /wFETY PERMIT (Lux rtEYb BELOW)
m
NO. OF EXITS
new and Professions Code,and my license Is In ftiH force and
effect PARKING REq'D rROVID ED
■PACE■
Licenw Number Liia Clam LIMITED TIME USE
Contractor Date DAT. DAT=
ElI am exempt from the Hag requirements as I am a FRONT TO:
licensed architect or a registered professional engineer ■rzE or ST I INsPEcroR's
acting In my professional Capacity (Section 7051, Bus- EXISTING BLDG. STORIES y ■16l1ATUR
inenand PTofessioniCodo). r FINAL APPROVAL
PRESENT U■E OF BUILDING
Lie,or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. of EXISTING BUILDINGS
ON LOT AND UfE - -
I hereby affirm that I em exempt from the Contmctor's ACCT.
License Law for the following reason (Section 7031-5, Bud-
nen and Professions Code): NO. PARKING 33D7 93.OD
I, as owner of the property, wM do the work and the /PACE/ PROVIDED 1 ITEM
structure Is not intended or offered for sale (Section
7041,Business and Professions Code). TOTAL 93 - 00
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CWK 93.00
I hereby affirm that there is a construction lending agency l fC4f
for the performance of the work for which this permit is el 'al
issued(Sea 3097,Civ.C.).
Lender's Name ���}j�'� /
PROPOSED MAX. OCC. '..P..R..ti 7.R.R.l1 4I 5/%
Lender's Addren /�,� r�P��J
I certHy that I have read this application and state that the PERMIT FEE IOC) 9913 1 111 7=L'i,
above information L correct I agree to comply wi��lCountyty 15BUANCE FEE Q
ordinances and State laws relating to building
and hereby authorize Iepmaentatives Of this County to enter TOTAL FE[
upon a above-mentioned pro for inspection pure
SEE REVERSE FOR EXPLANATORY LANGUAGE
igoature of Pe ee Date