HomeMy Public PortalAbout9008 - 9010 BROADWAY_Miscellaneous__ R ERs ONIPENSATION DECLARAnON E 874S �118a1
Cc MISCELLANEOUS APPLICATION
CST
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure. or a certificate of%torkeo; Cuntpensation Insurance.or
t� a certified copy thereof iSec. 3800. Lab.C.I.
Policp No. _Cmupam FOR APPLICANT TO FILL IN au aolrvc G�G,/C
❑ DURESS
Certified copy is hereby furnished. BUILD INc oeo E • CJr�ld wQ
?J ORE55 11 LOCALITY
1 I Certified copcis ;led wth the counn building intipectllt LOCAL17Y Temple lltY '..REST
department.
CROSS ST.
Date Applicant NEARESTSTR ^T N . GRCJJP TYPE ESSEO 9Y
CROSS ST. v P� �V` CON T
i CERTIFICATE OF EXEMPTION FROM Ti ORKERS LEGAL (/O G
C I)NIPENSA FI°!'' INSL RANCE OEiCPIPT:OY LOT NO. BLOCK I.ueP IGN\V av
Ci Le) STATE MAJOR SECOND LOCAL
JF 2LDG5.
Iy I$ $(:perm need not he completed If :he work involved {-q Ac- j:;O ''.: ON LOT USE 70N. s -CIA LRCONDITIONS
by the permit is for one hundred dollars iSlllgt or less.) use OF
SI:G JF LOT E.l'ISrING
1 certifc that in the per onrance a -lie :co;4 fu: chick :his
permit is issue(. I shall nm ;mPIOV enc ne-sen in any manner c:vNER A
so as mp
to beeotne subject ;o 'he 11'orke:s' Co mpensation !.a\cl. OI I OCCL'PANC'r 3ROUP i I —
°" 1D w 5a G la 0- 10'"P
UDR Ess —
I Dale Applicant1I _ _
NOTICE TO APPLICANT: It. aftc: mal-ir- ' -o::s Co-icarr 11-1 $1 CITY 7,1 nl ve(EA16559 -35;;L5 OCCUPAN- IOAC -
Exemption. you ;fundd beconl elec -o ,h \G,/kri I APOL'CA'IC1gI D:'F 3XI"- HAFCIa!?F -.
Compensition provisinns 1 :hc 1bI . .lie. oil .rust forth- —
{ \cith eon fy iInh u h rovis, l lllis :ermit shall be _ aILER USE = GEOLJCY Nsv- -!ON - R
deemed it"Uled. - - No Su_c. K: ewl. _
Lfl,ENSED CONIR.\CCFORS DECLARATION JCCUPANCY NSP.CTIONga F3riC Devices
I he:eb, 1arn1 :hat I am herased under^r C\l9Un.5 Jt C.a:IDte[ S.FEiY PERMIT '^ Iasi ITEMS SEI
-OW)
3EO a/.I u
9 Icommencine with Secien 70001 of Dnisio:l 3 of the Susi- No. OP ESITs
ness and P-ofessiors Code. and me license is it dlil iore rind — ' o
7C. 'L-GG� PV RKING 'O PR
REOCVIC E:]
'—CES
License NumberLia Cass
' LIMITED TIME USE
Cuntractnr Dlne.— _ — �..F o,>.
0 1 am esemp[ ;rum the :icensine reeuhemenic as : atr. .t
a t licensed a:gilitac: a; a :eeisrered p;ei easional :nrfneer srz. Oc ;G_ O INsRECTOR*S I
z actin- :n :nv Prot csefonal ::t^ cit _..:ion -I"I. Rua- EN IS-. eL=G. R E. smuaru RE
a fnessund Prnfessfcnsloda 1.
Pq.SENT USE OF euILJING FINAL A??RO\/AL
_ Lia or Re^_. NII.---- Rrc
110.NIE O\\'NFR-131ILDER DFCL:\R.UION NO. OF EXISTING BUILDINGS U (: -
��_9
ON LOT AND USE FEE
i hereby aifuni that I am exempt front the Contractor's (' I v/ c"Ir
�JI�
fohotcingi y
License Law for the reason 7.13i S. Uusi- 017100-00111 a . .
ness and Professions Cade): NO. PARKING I '-I37.I] I Artti1:40
FJ1.
r I
1, as owner of ;he properiv, will du :7,•c work and the SPACES PROVIDED
structure is not intended or offered for <.dc (Section
7044.Ifusin",;anl Professions(odel. X PROPOSED USE OF BU1y/vLA
BUILDING f�
CONSTRUCTION LENDING AGLNCI Las SI f1o )
r 1
I hereby affirm that there is a construction lending :wenn' d mtt^
a '
for the perfurmmnce of the Bork for vcluch this permit is _
issued (See 3097,Cie.C.).
Lender3 Name
PROPOSEO OCC.
Lender's:Address
I PERMIT FEE 25.00
1 certify (lift I have read this application and state that the
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction.
and hereby authorize represetitatbres of this County to enter TOTAL. FEE 25.00
I upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGU:\GE
1
Signature of Permittee Date