HomeMy Public PortalAbout9331 BROADWAY_Miscellaneous__ WORKERS'COMPENSATIONDECLARATION 76M444 MISCELLANEOUS APPLICATION
CE 875(11.84) J�I
I hereto affirm that I have a s'Co is te ofCompensation
consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION L1'Ljll
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADORE 55 '!✓JI E �.�
Certified Copy is hereby furnished. BUILDING
RE
AD ORE J / �. L.� LOCALITY
ADD /
Certified copy is filed with the county building inspection LOCALITY a NEAREST
department. �2 1e��J CROSS ST.
Date Applicant NEAREST DIST ICT NO. GgOUP TYPE ESSEv OY
CRDs5 ST. ` // CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (/ 'Y. -1
COMPENSATION INSURANCE DKSCRIpnory LOT Me. BLOCK
rvoP NOOF SLOGS. (CIRCI-E) STATE MAJOR SECOND LOCAL
.
(This section need not be completed if the Work involved TRACT NOW ON LOTUSE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (5100) or less.)
SIZE OF LOT USE TI /
I certify that in the performance of the work for which this �^ Exlsnpe BLDG.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. �J� m
MAIL r OCCUPANCY GROUP 9Y - o
Date Applicant wv DREss < j /L W
�„ «�� TEL. y Y>3 OCCUPANT LOAD - H
NOTICE TO APPLICANT: If, after makingthis Certificate of cITY No.
Exemption, you should become subject to the Workers' ?
Compensation provisions of the Labor Code, you must forth-- AP LICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be
deemed revoked. ❑
TRAILER USE E] GEOLOGY INSPECTION E] No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
1 hereby affirm that 1 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 ! /J
effect. NS L .z f Q PARKING pEOD pgOV10EO
LicLYlse Number Lic. Class � � �� SFACEE
.,
LIMITED TIME USE
Contractor Date 65(.4 pp y b DATDATE
ElI am exempt from the licensing requirements as 1 am a /, PL J I W) 4�! J AL_ P
licensed architect or a registered professional engineer ""OFNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES a SIGNATURE
iness and Professions Code). `� FINAL APPROV AL y ,r
PRESENT USE OF BUILDING L
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS vU
ON LOT AND USE 3
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- c
ness and Professions Code): No. PAp KING _ f1
ElI, as owner of theproperty, wit] do the work and the spwces p..YIOED
structure is not intended or offered for sale (Section _
7044,Business and Professions Code). i{ITAL 234 . 45
.PROPOSED USE OF BUILDING U '%,/
CONSTRUCTION LENDING AGENCY I_HECK ,...
1 hereby affirm that there is a construction lending agency CHAKE
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.Q.
Lender's Name
Lender's Address
PROPOSED MAX. OCC.
L_ _ r'
PERMIT FEE �� ,�J irli 1 �'I•I °'I.i
1 certify that 1 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-mentioned pr Perry for ins ection purposes. '
SEE REVERSE FOR EXPLANATORY LANGUAGE
re f Permittee Date