HomeMy Public PortalAbout9238 BROADWAY_Miscellaneous__ R'QRKERS'CODIPENSATION DECLARATION
CE 875(11-84)44 M ISCELLANEQU. S APPLICATION {� .
CE LJ
1 air, .affirm that I have a certificate of consent to self - COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
irfsure, or a certificate of Workers'Compensation Insurance,of
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
_ ADDRESS
Certified copy is hereby furnished. BUILDING �1 7 p W
ADORE' 23 o4 `,yLOCALITY
Certified copy is filed with the county building inspection -
department. LOCALITY - -t�l)�� G�f NEAREST
i/ CROSS ST.
Date Applicant '-' NEAREST 1-/ Li'r1� /T 1 4 DISTRICT NO. G OUP IT pE PR 59ED BY "
C R055 sT. �r 11// If(r /� v 0— CONST:
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J /Y/
COMPENSATION INSURANCE oescRlPnoN LOT NO. BLOCKmNww
ryQP (CCLEI STATE MAJOR SECOND LOCAL
NO. OF BLOGS.
(This section need not be completed If the work involved TRACT 4/ NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) .SIZE OF LOT" 0200 USEXISTINGr E of o_/ 1,417 /
'BLDG. L1 �GS d
I certify that in the performance of the work for which this l� '
permit is issued, I shall not employ any person in any manner OWNER AUL vVAA16T -
so as to become subject to the Workers' Compensation Laws. z
MAIL p OCCUPANCY GROUP
Date Applicant ADDRESS- 92 j (7 '� OAPW4 ..
I LU
��/ L,Z C rEL OCCUPANT LOAD
NOTICE TO APPLICANT: If, after makingthis Certificate of CITY NO.
Exemption, you should become subject .to the Workers _ z
Compensation provisions of the Labor Code, you must forth- APPLICATION F EXIT HARDWARE:
with comply With such provisions Or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. .�
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) -
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code, and my license is in full-force and G /1 Uj/
effect �/ t/ f� 64THR PARKINSPACESG REO•D pROV106p
License Number Lic. Class /C
LIMITED TIME USE
Contractor Date - - DAT. DATE
I am exempt from the licensing requirements as.I am a - TD"
licensed architect or a registered professional engineer SIZE OF NO, OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
hies$and Professions Code). FINAL APPROVAL / �r
Lic.or Reg.NO. Date PRESENT USE OF BUILDING 7
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE
1 hereby affirm that 1 am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and ProfessionsCode): NO. PARKING
[, as owner of the property, will do the work and the SPACES PROVIDED = NPI",
structure is not intended or offered for sale (Section _
7044,Business and Professions Code). I CI THL !4L _ 7
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING - n—'�hs -' �="• -�
I hereby affirm that there is a construction lending,agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). - -f.41
Lender's Name
`t Lender's Address PROPOSED MAX. OCC.
_
PERMIT FEE O,m-Q 1`�I,_
1 certify that'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 representatives of this County to enter TOTAL FEE
upon the above-m ntioned erty for inspection purposes.
i
3 � Z SEE REVERSE FOR EXPLANATORY LANGUAGE
SignituA of Permitte\ Date
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