HomeMy Public PortalAbout9829 BROADWAY_Miscellaneous__ WORKERS'COMPENSAT74NDECEARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION {�
CE 875 LJ
I hereby affirm that ofI'haveWoo certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'
rs'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLI CANT TO F I LL I N ISUILOIrvG qpq �•
AD OR E55
AIL ENG q
Certified copy is hereby furnished. BUILDING A1? �4Ra�u/ALOCALITY
y
0 Certified copy is filed with the county building inspection LOCALITY ?EROPLE- C/ CROss sr. OF
department. f^
Date Applicant NEAREST WLY til ..1�� DISTRICT NO. G OUP TYPE PROCESSED BY
CROSS $T. (J(/ GIV WWG/ {�.D� _ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK IGXWA
(C Lel STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if tie work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
SIZE OF LOT EXISTING BLO G. —/ � CL
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner OWNER (5,6696AF H. If JOAnI T P/SKG y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP �_ 3
Date Applicant ADDRESS 306 SAPv "is ReY ?O, C7,
- TEL. W
NOTICE TO APPLICANT: If, after making this Certificate of CITY fl'RCADIA/T No. `lq J-660 3 ' OCCUPANT LOAD D-
A
Exemption, you should become subject 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 ❑
deemed revoked. ❑ ❑ 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 Ewrs
ness and Professions Code, and my license is in full force and
effect. L-"7ClSTIilI6 770 PARKING
SPACES REq'O E� PROVIO ED D
License Number Lie. Class LIMITED TIME USE
Contractor Date AT. GATE
I am exempt from the licensing requirements as I am a 1.
licensed architect or a registered professional engineer SIZE oPNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. IZOO SQ � � STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
Lie.or Reg.No. Date
PRESENT USE OF BUILDING
L
HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS
s
ON LOT AND USE aT
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING � CI'IG
_
1, as owner of the property, will do the work and the SPACES PROVIDED
- —
structure is not intended or offered for sale (Section }.11rL
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency 441 Fat .12(
for the performance of the work for which this permit is ,
issued(Sec. 3097,Civ.C,).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address '`1�� .i fap11_oq_
PERMIT FEE
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 G sj D
ordinances and State laws relating to building construction, '1
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�Na!/. 8y 1991
nature of Permitte Date