HomeMy Public PortalAbout8920 BROADWAY_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 375 (2-80) MISCELLANEOUS APPLICATION {�
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Lf
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 8mLDiNG
ADDRESS
Certified copy is hereby furnished. BUILDING O LOCALITY
ADDRESS L(zg
❑ Certified copy is filed with the county building inspection
NEAREST
department. LOCALITY CROSS ST.
Date Applicant NEARESTE//y EA DISTRICT NO. OR P TYPE PROC $E;BY
CPIGS S ST. 0S CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK M Icn WAY T
.... (CIPCLEI STATE MAJOR SECOND LOCAL ta,
ThiSeCflOn need ❑O[ be com le[ed If the work involved NO. OF BL USE ZONE SPECIAL CONDITIONS Q
t P TRACT NOW ON LOTT
by the permit is for one hundred dollars (5100) or less.) U
n
E !�
SIZE OF LOT US TITI NG SLOG. ` ✓✓✓✓✓✓ 0
I certify that in the performance of the work for which this uS
permit is issued. I shall not employ any person in any manner, OWNER(9041 N
so as to become subject to the Workers' Compensation Laws. MAIL
OCCUPANCY GROUP U
ADDRESS/
Date Applicant 1 /tet N
NOTICE TO APPLICANT: If, after making this Certificate of cITY U .O �f` rvo� 7�Y�pj�l 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 E] 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 BELOWI NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and ProfessionsCode, and my license is in full force and PARKING.
effect. SPACES REO'p E= PROVIO ED D
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATA DATE
❑ I am exempt from the licensing requirements as I am a FROM TO
licensed architect or a registered professional engineer SIZE OF no. of IrvsPE Aro R's
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES slorvaruRE
iness and Professions Code). FINAL APPROVAL y-
PRESENT USE OF BUILDING
Lic.or Reg.No. Date ^^ Cr
HOMEOWNER-BUILDER DECLARATION NO, OF ON LOT AND USE AND USE BUILDINGS
��''qq..,,
I hereby affirm that I am exempt from the Contractor's —v/ TGJY A —0 1 1.4A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING # -7,c9-.-._..,
❑ I, as owner of the property, will the work and the •
structure is not intended or offered
8 0,'5 0
SPACES PROVIDED 4, 2'• 0
d for sale (Section //'1�J/ J
7044, Business and Professions Code). PROPOSED USE OF BUILDING �� (/ O O'e 805060
V
CONSTRUCTION LENDING AGENCY 0 3 3 0-8.4,
1 hereby affirm that [here is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MA%. OCC.
Lender's Address O
PERMIT FEE r
1 certify that I have read this applies ion an state that the
above information is correct. I agree t comp) ith all County ISSUANCE FEE
ordinances and State laws relat'n to but ng construction, Tor AL Fes O. �O
and a authorize represe f as of s County to enter
t7r ab e- ntioned p rty for nspect' n pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
ath of Yer