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WORK)RS'COMPNSATIONDECLARATTON CE8 6`(tt-84) MISCELLANEOUS APPLICATION
1 herotiaffirm that I have a certificate of consent to COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
hmaLre, o or �tificate of Workers'Compensation Insurance,,or or
a cartif'ied copy thereofl(Sec.3800,Lab.Q.
Policy No. 7 Company FOR APP LICANTTO FILL IN ■U ILDINa /
AD ORKSf .,-
FICertified copy Is hereby furnished. BUILDING LOCAL—
ADD.[// 33 8 AM IV 1164 04-,e-
Czrfflod
department copy
Is Mad with the county building inspection LOCALITY / p NK AR K,T /� C
CRO■■ ST. !C
Date Applicant NKARKST DISTRICT NO. a OUP rK rR KSSKD BY
CROSS ST. �,[ CONS'.
CERTIFICATE OF EXEMPTION FROM WORKERS' LKaAL J �I
COMPENSATION INSURANCE DL■CRIrT10N LOT NO. I.L.C.CIC YAP H10HWAY
XO. (CIRQL/) STAT[ MAJOR St COND LOCAL
NO. BLJ7G/.
Mils aeCtlon. need not be co
Ieted if the work involved TRACT NOWOP OX LOT / USK ZONK nPKCIAL CONDITIONS
by the permit is for one' hu dollars ($100) or leas.) - USK Ow
SIZK Or LOT KXI/TING BLDG.
I certify that In the performance of the work for which this CD
permit Is issued, I shall not employ any person in any manner O.N[R
so as to become subject to theZ�r
mpensnti Laws C OCCUPANCY GROUP o{---.�/Or,� MAIL � Mt3Date A llant r14, ADDRi/S J
TKL.
NOTICE TO APPLICANT: If, after making this Certificate of arty TAt 7 No. /jr- _� OCCUPANT LOAD
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code,you must forth- A PLICATION FOR EXIT HARDWARE:
with comply with such provisions oI this permit sbaIl be TRAILKR USK ❑ ozoL.OGY INSrzaTIoN ❑ No Spec. Know[.
deemed revoked.
LICENSED CONTRACTORS DECLARATION oacurwNcv IN/rKCTION ❑ Panic Devices
I hereby afflffi that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi swrKTY rKRYrt ❑ (LIST rtKY/ ■KLo>t)
NO. OF KXIT/
non and Professions Code,and my License is in full force and
�� PARKING 1rACK1 Rtp'D 1-.011 15
License Number Lia Clan /mss s7bL'
/�� ..ar /may LIMITED TIME USE
Contractor Date DAYS DAT/
TD,
0 1 am exempt from the Licensing requirements as I am a '� 9��i rROYI
si
licensed architect or a registered profbssional engineer 1IZK Or NO. Or IN■PKCTO. s
acting In my prof&donal capacity (Section 7051, Bus- XXISTING BLDG. 1176 1/TORIK■ RIG u.K
Ines and Professions Code).
FINAL APPROVAL
Lie.or Reg.No. Date rRK/KNr USK or ■u1LDlno
HOME OWNER-BUILDER DECLARATION No. or K%I/TING BUILDINGS
ON LOT AND USK
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Bust- 3307 93.CC,
nen and Professions Code): No. F"KING
El 1 ITEr'
I, as owner of the prowill do the worst and the ■PACK■ PROVIDKD 1 i'CI w
structure is not intended or offered for sale (Section
7044,Business and Professions Code). Ti_ITA- 9:3 - 00
CONSTRUCTION LENDING AGENCY PROPOSKD USK Or BUILDING // HL[E 93.00
1 hereby of Irm that there is a construction lending agency [ .10
for the .performance of the work for which this permit Ia
issued(Sea 3097,Ctv.C.).
Lender's Name PROP O/KD MAX. OCC. }'030—"1 12/26/913
Lender's Addmn ���;�',�� A�M�,,{
P[RMIT FC6 'h7�JJ � F'LI 31:it,,,
I om-tify that I have road this application and state that the
above information is correct.I agree to comply with all Couhty 188UANCK raK �3
�;
ordinances and State laws relating to buflding oonstruction,
and hereby authorize representatives of this County to outer TOTAL RKK
Z=
abo mentioned p party for inspection purposes.qct SEES RSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Data