HomeMy Public PortalAbout9144 BROADWAY_Miscellaneous__ :E RS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION {�
I CE 875(11-84) Ll
I h affirm icat 4 have Workers'
C Compensation
of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insu oi'.acertificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800, Lab.C.).Policy No. CompanyFILL
BUILDIrvG r/ 2� _
FOR APPLICANT TO FI L.L/IN ADDRESS `/ e •
Certified copy is hereby furnished. BUILDING /� �nOhIOW/¢/ '
ADORES. /T LOCALITY 7
ElCertified copy is filed with the county building inspection LOCALITYNEAREST
department. ' CROSS ST.
Date Applicant - NEAREST DISTRICT NO.: �G UP TYPE PROCESSED BY
CROSS ST. LOp/A oAPu7A� CONST.
CERTIFICATE OF EXEMPTION.FROM WORKERS' LEGAL '
COMPENSATION INSURANCE - DESCRIPTION LOT NO. �' BLocX. - - _...—Al
NO.MAP IuRc�el STATE MAJOR SEC N° OCAL
NO. OF BLDGs.
(This section need not be completed If the work involved TRACT N
OW ON LOT �+ VSE ONE S °ITIO
by the permit is for one hundred dollars ($100) or less.) of
I certify that in the performance of the work for which this III.. of LOT �2 X 1�o E%ISTING/BLDG. �F d
permit is issued, I shall not employ any person in any manner OWNER 60 S4vW JAl
so as to become subject to the Workers' Compensation Laws. MAIL _ /nI OCCUPANCY GROUP o
Date Applicant ADORE55 SD Rt e� acsz-�
' U
NOTICE TO APPLICANT: If, after making this Certifbate of CITY O Ay NO. 3— 3/--2 OCCUPANT LOAD
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code, you must forth- PPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be
deemed revoked. TRAILER USE ElGEOLOGY INSPEcnoN ❑ No Spec. Kriowl.
LICENSED CONTRACTORS DECLARATION -
OCCUPANCY-INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 Of the Busi- SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO OF EXITS
ness and Professions Code, and my license is in full force and
effect. �/y� AGT ��� r
/�! TN� T/J P. K.-e REO'O � PRO
VID EO 1 I
SPACES �J
License Number Lic. Class L—�i1�LX-OS E /x/3' 9,✓D zw,- AND LIMITED TIME USE
Contractor Date •• r4tR ?O /Y) K.E 4 fP4L 6/17-H DATE DAT.
I am exempt from the licensing requirements as 1 am a '[elPok d, BiL �h$1A4 �C/�T E a✓ P
licensed architect or a registered professional engineer SIZE OF ,$j--S/ Cr Gc)CTEG'io o. of INSPECTOR'.
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG, O Sti STORIES 1 ATURE (1
iness and Professions Code). - FINAL APPROVAL
Lic.or Reg.No. Date P
• RESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS - -
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ACCT,A License Law for the following reason (Section 7031.5, Busi- .ACCT 1 ITEMS SII 5[1
W-
1,
ness and Professions Code): � NO. PARKING _ -. - _ . C�
SPACES PROVIDED l8 P
1, as owner of the property, will do the work and the TOTAL +-ice a
structure is not intended or offered for sale (Section _ - OQ,--11
7044,Business and Professions Code). CHFE`C,
PROPOSED.USE-OF BUILDING y- - {,HI'IH(�E Pfhl
CONSTRUCTION LENDING AGENCY - �� r '
I hereby affirm that there is a construction lending agent
ee"
for the performance of the work for which.this permit is � - O
issued(Sec. 3097,Civ.C.). QQI)Q—I)I)1)1 1/ b/LA
Lender's Name
0 1
PROPOSED MAX. OCC. ' 1L 25
Lender's Address
- '
I certify that I have read this application and state that the PERMIT FEE- `
above information is correct. 1 agree to comply with all County ISSUANCE FEE ,/O_J
ordinances and State laws relating to building construction, ^O -
and hereby authorize representatives of this County to enter TOTAL FEE - .J -
upon the above-mentioned property for inspection purposes.
/ / Q p SEE REVERSE FOR'EXPLANATORY LANGUAGE
Sig iture Permittee �S Date j