HomeMy Public PortalAbout9214 BROADWAY_Miscellaneous__ - WCR2KER5'COMPENSATIONDECLARATION
CE 875(11 84?. - MISCELLANEOUS APPLICATION
.. -_ - - CE 75 - - "r
I hereby-affirm that I have a certificate of,.consenttto self ': _ COUNTY OF LOS ANGELES: - - BUILDING AND SAFETY-DIVISION - -
insure, 'or a certificate of Workers'Compensation Insurance,or
-
a certified copy;thereof(Sec. 3800,.Lab.C.).
Policy No.—Company =NG
NG
FOR APPLICANT TO FILL IN wu DR ess" e
Certified copy is hereby furnished. .- _ L
I
BUDING
ADDRESS C,Z�. ����p w�y
/ `Y LOCALITY
El Certified copy is filed with the county building inspection - --C�
L `
- department. � DRoss sT.
` OCwLITY NEAREST
Date Applicant NEAREST DISTRICT NO, GROUP Ty-'N5-
VPE PR sED BY
CROSSST. ,Ale_IAIi'74S 1' � CONST
CERTIFICATE OF EXEMPTION FROM.WORKERS' LEGAL 41 x
COMPENSATION INSURANCE, . DE ICR PTI ON LOT ... T7 eLocN q/, 1 :A -
_ NOP G,tJ/ cw CL¢I STATE MAJOR gEC D OCAL
/ J/ NOl OF BLDGS.
(This section need not be completed if the work involved TRACT M 1.114 E NOW ON LOT Z USE.ZON SPECIAL CONOIT ION9
by the permit is for .one hundred dollars ($100) or less.) -
SIZEOF LOT c'/ -7
I certify that,in the performance of the work for which this �& X /t�
EXISTING BLDG.
"�
permitisissued, I shall rio{employ any person in any mariner OWNEa ' G VZ4 - /Y1A7/t/ I - - ., - v
se as to be'Jcomeosubjecf tb the rkers' -ompensahon Laws. MAIL /tel ,Jp OCCUPANCYGROU P v
\l O_ �.n AOIL 7. O/<O�LYr/Q / �� • .' �. U
�ll ate Applicant
NOTICE TO APPLICANT: I , after-Makin this Certificate of clrY C,,^ /` ' TEL. /��z�,��"�/ OCCUPANT LOAD a
Pa ��/'/�u G/T� NO. y
Exemption, you should become subject to the Workers' 'z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR _ EXIT HARDWARE:
with comply with such •provisions or this permit shall be TRAILER USE ❑ 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 BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- E /_ NO. of Exrrg
ness and Professions Code,and.my license is full force and / �� ��L / O hl F��� P Rrcirlc
El
effect K.�-r-'�{� /y17- R. PROVIDEO. �-J
7-t) 13Z7
- - ..- �' - I •I � r /T C7��— GaEs� gP CES
License Number Lic. Class
Contrctorr - .Date (� clSc ZZ ' ,Z Y DATE
LIMITED TIME USE DATE
I am exempt from the licensing requirements as I am a - 7 r 3 I - -
licensed architect,or a registered professional`engineer S,zE DF / rv0. of INS,ZCTOR'S
acting in my Professional capacity (Section 7051, Bus- EXISTING BLDG. f _m STORIES g rvwruRE
-w.iness and Professions Code). -
' PRESENT USE OF BUILDING / ��Jl/� � INAL APPROVAL
��;.or Reg.No. Date ,L
HOME 01VNE R-BUILDER DECLARATION No. OF EXISTING-Bar Gs )»
ON LOT AND USE ef
I hereby affirm that I am exempt from the Contractor's
License Law fox the following reason (Section 7031.5, Busi- Ca `y4• _
ness and Professions Code): NO. PARKING ( } JJ j„�
SPACES PROVIDED Z- G7'
I, as owner of the property, will do the work and.the
struch¢e is not intended or offered for sale (Section /a-.�, 'o ' ����
7044,Business and Professions Code). L
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
h
I hereby affirm that there is a construction lending agency 'J� �'( r 3 `/ 111iiE
f --
for the performance 'of the work for which this permit is ' '-PE' & •
issued(Sec. 3097.Civ.C.).
Lender's Name t HECK 3i 1, Il l
- - PROPOSED MAX. Dec. LHC�''La
I�'
Lender's Address <<1ij
PERMIT FEE 0, oU
I certify that I have read this application and state that the ,
above information is correct.I agree to comply with all County ISSUANCE FEE 10
ordinances and State laws relating to building construction, -=,. -i 1'_/L"
TAL
and hereby authorize representatives of this County to enter TOFEE - ,50 - , _ -ey; A r: :-..:1.-
up lie above-mentioned'property for inspection purposes. - - 1 - `'t i
SEE REVERSE FOR EXPLANATORY LANGUAGE
. .Signature of Permittee .Date6// - _