HomeMy Public PortalAbout9070 BROADWAY_Miscellaneous__ 'O RICERS'COhiPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION
CE 8]5 (11-84) J�I
I hefe I (firm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Lllull
insure, -care of Workers Compensation Insurance,or
a certifre y thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL INno oaess Q
FICertified copy is hereby furnished. BUILDING
F-1Certified
o7C� �, �j'ZO:ap W:��( LOCALITY
Certified copy is filed with the county building inspection LOCALITY-T /�� NEAREST
department. 1 t= YIA IP L,S k L.W CROSS ST.
Date Applicant NEAREST y S J� DISTRICT N ROUP PE PROLE ED BY
CROSS ST. 4W CO
NST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT No. 3 BLOCK D RAP, 1� (CIw CLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT I I Z- V NO. of BLOcs. -7
UP
IS ON LOT J U20NE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($I00) or less.) / .� USE OF
I certify that in the performance of the work for w h this SIZE OF LOT �I� ((00 - EXISTING BLDG. 1
permit is issued, I shall not employ, any person roan in
OWNER pJ- QQIZIg 1 CJ pC,-D —/a YL(j v
so as to became subject to the Wor s' C pensat Laws. MAIL S OCCUPANCY GROUP s
ADDRESS
Date ::y.rt LZ'Applicant WI' ( t3
NOTICE TO APPLICANT: If, after making thisVee of CITY TNa-L g(iii Z�_]398 OCCUPANT LOAD N
Exemption, you should become subject to the Wor ers' z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be ❑ -
deemed revoked. E] ElTRAILER USE GEOLOGY INSPECTION No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION' ,Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT
❑ (LIST ITEMS BELow)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. L 6A-L {� &.� -
� \Z L,
70 V -- Y`(S ` 1 PARKING REO'O � pROVIO EO
SPACES
License Number Lic. Class ALD01 =00
LIMITED TIME USE
Contractor Date DATE
Elam exempt from the licensing requirements as I am a pi TIn rl DATR
licensed architect or a registered professional engineer SIZE ofNo. OF INSP CTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG_. STORIES sI ArURE
iness and Professions Code).
PRESENT USE OF BUILDING p t. O ��`6' FINAL APPROVAL
Lic.or Reg.No. Date �J
HOME OWNER-BUILDER DECLARATION NO. OF 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, Busi- 1_._......:................... _ 1} �rITE '. -may s
ness and Professions Code): NO. PARKING - --•_ __ ___ '__ __ TOTr1L 80
1, as owner of the property, will do
PROVIDED do the work and the .... ._,. - "
structure is not intended or offered for sale (Section CHECK
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING $
I hereby affirm that there is a.construction lending agency - - � 6/22, Y'-
for the performance of the work for which tris permit is . _ Y;.
issued(Sec. 3097,Civ.C.). 4113 41131 AM P'*14
PROPOSED MAX. OCC. '
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws rela 'ng to building construction,
and hereby authorize represent• Ives of this County to enter TOTAL FEE Q
upon the ab a-men 'oned prop try for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perrow.ev Date