HomeMy Public PortalAbout9557 BISBY ST_Miscellaneous__ w� Rs'COMPENSATION DECLARATION CE 878(11-84) M ISCELLANEOUS APPLICATION
I hereby affirm that I have a cartificate of consent to self LOGY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insuro a certificate of Workers'Compensation Insurance,or
a copy thereof(Sea 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN ■DILLI
ADDRES2/1
Certified copy is hereby furnished. .--,NG LOCALITY
ADDR[1/
Certified copy is filed with the county building inspection LOcALITv N[ARE/T
department. CRO■■ ST.
Date ii''��••.�",'. ApplicantHEAR[/T DI/TRICT 6 TYr6 PRO / D .Y
CRO■■ ■T. l/!//1 COH1T
CERTIFIQATE OF EXEMPTION FROM WORKERS' LEGAL `
COMPENSATION INSURANCE D[SCRIPTIOH LOT NO. ■LOCK YAP HMH AY
Ho. (CIRCLL) RTATE MAJOR ■[ D LOCAL
//����,,��''
NO. OF ■LDG■.
Cl'k6 section need not be COInpieted if the work involved TRACT NOW ON LOT ;kO
ONE SPEC D H
by the permit L for one hundred dollars (5100) or lar.) USE or
I cer- fy that in the performance of the work for which this SIZE OF LOT [XI/TIME ■LD 6. � O
permit is issued, I shall not employ any parson In any manner OWNERbarn 'JOA rK s'
so as to become subject to the Workers' Compensation LaWL CCUPANCY GROUP °C
MAIL
ADDR[/R l LU
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of cITvle HoL f OCCUPANT LOAD
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth-
with
ortes A LIGATION FOR EXIT HARDWARE:
with comply with such provisions or this permit dull be TRAILER USX ❑ G[oLOGY IN/r[aTIoN ❑ No Spec. Knowl.
deemed revoked_
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION El
Devices El
I hereby afflrm that I am licensed under pr ns of Chapter
9 (commencing with Section 7000) of Dfvisiono3 of the Bush lwr[TY �ERMrt E] (LIST rtEM■ BELOW)
NO. OF EXITS
nets and Professions Code,and my license is in fall force and
effect._ PARKING REp�D rROVID ED
SPACES J
License Number Lia Chas A e- /
/�� �y tL LIMITED TIME USE
Contractor Date removed l am It DATI DATI
ElI am exempt from the ling requirements u I am a 1al q
honied architect oI a registered profbasional engineer SIZE OF n�,l �r NO. or �woYl roI IH IG T R'1
acting in my profatdonsi capacity (Section 7051, Bus- KXISTING ■LD /10 TUR[
Eats and Profesdons Code). gj
FINAL APPROVAL
Lia or Reg.No. Date 17—
PRESENT U/[ OF BUILDING
HOME OWNER-BUILDER DECLARATION No. or 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, Buri- 8 8 7.4 A
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the /PACER PROVIDED # 0'0 0.0 30
structure is not Intended or offered for sale (Sectlon I - 8Q50
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED ul[ or BUILDING D 0.0 8 Cl 5 0
I hereby afTlrm that there is a construction lending agency 0 1,29-88
for the performance of the work for which this permit is
issued(Sea 3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FE6
I certify that I have read this application and state that the
above information Is Correct.I agree to comply d�with
construction,alllinty te5UANCR REQ
ordinances and State laws relating to
and hereby authorize representatives of this County to enter TOTAL FHE
upotloa?ppinvInspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Permittee Date