HomeMy Public PortalAbout9903 BROADWAY_Miscellaneous__ WORKERS'COMPENSATION DECLARATION Woo 76Ma4a y.ATION
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I hereby affirm, that I a certificate of consent to self COUNTY OF LOS ANGELS BUIL*,TG A4,ND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a cer?ified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLI CANT TO FILL IN BUILDING
❑ pOpR E55 /
Certified copy is hereby furnished. Bu uo1NG �'y Iu�/ w� r
ADOR ESE O ✓Y LOCALITY
FICertified copy is filed with the county building inspection LOCALITY
NEAREST
department. .e If- tr ceoss sr.
Date Applicant NEAREST DISTRICT NOyy GROUP TYPE CESS-EO BY
CROSS ST. ^ D // —3 CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a
COMPENSATION INSURANCE BESCRIPnory LOT NO. HIGHWAY
IC LE1 STATE MAJOR SECOND LOCAL
NO. OF BLDGS. Na ' C
(This section need not be completed If the work involved TRACT NOW ON LOT USE ZONE SPECIALCONDITIONS
by the permit is for one hundred dollars ($100) or less.) SIZE OF LOT EUSXE of
ISTING BLDG. d
I certify that in the performance of the work for which this o
permit is issued, 1 shall not employ any person in any manner OWNER ='
so as to become subject to the Workers' Compensation Laws. r v MAIL �/ � OCCUPANCY GROUP
AD FESSS /// F�ezlyts+7 "✓.4
Date Applicant uJ
NOTICE TO APPLICANT: If, after making this Certificate of CI� f1C�Pq no� -2 -� OCCUPANT LOAD - yr
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 pxovisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
El
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 E] (LIST ITEMS BELOW NO. OF EXITS
ness and Professions Code, and m license is in full force and
effect. 1 r
y rPARKING RED PARKING
PROVIDED
A 7 Ger f�
SPACES
License Number Lic. Class - LIMITED TIME USE
Contractor Date � o.TE
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF No. of INSPECTOR'S
acting in my professional capacity (Section 7051, Bus-
EXISTING BLDG. sr oRlEs sic NATURE
iness and PIofessions Code). FINAL APPROVAL
Lic. or Reg.No. Date PRESENT E OF BUILD ING
HOME OWNER-BUILDER DECLARATION No. of EXISTING Bu1LmrvGs
ON LOT AND USE
r;
I hereby affirm that 1 am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING {'
SPACES PROVIDED 1 LIL{IJ
1, as owner of the property, will re the work and the T
structure is not intended or offered for sale (Section !i_1,,HL -�+s3- >,
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSE SE OF BUILDING i HE',_:K
I hereby affirm that there is a construction lending agency .,UI' 1.-''-
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 ;i-o�,
PERMIT FEE Z7
I certify that I have read this application and state that the
above information is correct. 1 agree to comply with all County ISSUANCE FEE6
ordinances and State laws relating to building construction,
olid hereby authorize representatives 94 this County to enter TOTAL FEEpl T /�
upo F a ve- eentio d property nspecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pe ttee