HomeMy Public PortalAbout9711 CRAIGLEE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS /� f� p q p
_1 ' CE 875 (2-80) s v 1f,—` Its�C AT I O N
I herebypaffirm"that I have: a certificate of consent to"self COUNTY OF LOS ANGELES BUILDING ,44D SAFETY DIVISION �.
insure, or a certificate of Workers'Compensation Insurance,or y.
a certified copy thereof(Sec. 3800,Lab.C.)
-Policy No. CompanyFOR APPLICANT TO FILL IN ADDR IJ�
ADDRESSSS.,( (f
,O Certified copy is hereby furnished. BUILDING / r ��T LOCALITY
F] - ADDRESS e' C L "f
Certified copy is filed with the county building inspection
LOCALITY NEAREST - �\
department. 71
G, �� ci> cRoss sT.
-Date Applicant NEAREST / �� DISTRICT NO. GROUP TYPE PROCESSED BY '
CROSS ST. �C/'T- 2 CONST. \; _
CERTIFICATt,OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT No. (1�, BLOCK MAP HIGHWAY' }
NO. (CIRCLE) STATE MAJOR SECOND LOCAL t1•
(This section need not be,Com leted if the work involved j/!� of BLDGs:
p TRAC � wA 'OYOW ON LOT US ZONE SPECIAL CONDITIONS OU
by the permit is for one hundred dollars ($100) or less.)
USE OF
SIZE OF LOT. - EXISTING BLDG. -
I certify that in the performance of the work for which this O
permit is issued, I shall not employ any person in any manner owrvERG l—
so as to become subject to the,Workers' Compensation'Laws. tiIAIL, //���J/� //� /r" OCCUPANCY GROUP w
ADDRESS �7�I '�--�C-6•Y'J ...�'! _ 0-
Date
Date Applicant to
TEL. Z
NOTICE TO APPLICANT: If, after making this Certificate'of ( clrY � �[" ,�: NO..
OCCUPANT LOAD —
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit,shall be TRAILER USE O. GEOLOGY INSPECTION❑ No Spec. Knowl. ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCYINSPECT Panic DeVIC@S ❑
I hereby affirm.that I am licensed under provisions of Chapter, , SAFETY PERMIT Q (LIST ITEMS BELOW) No. OF ExITs`.
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is'in full force and /J�
effect. _ W�y /7/lC, C/S r0/- PARKING. .
SPACES; REQ'D_ . PROVIDED D
i ' LIMITED TIME USE
License Number Lic.Class
Contractor Date DATE, DATE
aFROM: . :TO: .
I am`exempt from the licensing reyuirements.as I-ama
licensed architect. or a.tegistered professional engineer SIZE OF.: NO. of INSPECTOR'S
acting In my-professional.capacity. (Section 705 1, Bus- EXISTING BLDG. STORIES f'' - S NATURE
IneSS and PlOfeSS1UtIS COde). PRESENT USE OF BUILDING FIN AL`APPROVAC
Lic.'or_Reg.No Date_ J
NO.OF EXISTING BUILDINGS
HOME OWNER-BCILDER-DECLARATION ON LOT AND USE 8;0,5 0 -
I hereby affirm that' I am exempt from the Contractor's °;° ° 8 Q5 0.
U
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code NO.PARKING .' #®.
)' °' SPACES PROVIDED - - o 7.2.7 u 1/
❑ I, as owner of the,property, will do the work and the �.
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
PROPOSED USE OF BUILDING -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there 'is a construction lending agency,
for' the .performance .of the work for w-hich this permit.is
issued(Sec. 3097,Civ.C.).
Lender's Name
. � -PROPOSED MAX. OCC. -
Lender's Address PERMIT FEE
I certify that I have read this application and state that the i
ISSUANCE FEE
above information is correct. I agree to comply with all County L f
or 'nances and to laws relating to building construction, TOTAL FEE
d hereby auoriie representatives of this County to enter
upon.th abo -menti n'd property for inspecti n'pur os. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date