HomeMy Public PortalAbout9524 FLAHERTY ST_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE 876(1 1 84) MISCELLANEOUS A P P L I C A T I O N
I hereby of cert that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Workers Compensation Insurance or
a c3ttlfied c-ny thereof(Sec 3800 Lab C)
Poh±y No CompanyFOR APPLICANT TO FILL IN ADDRESS 7i
Certified copy is hereby furnished BUILDING G F`�HE S� LOCALITY G
ADDRESS
ElCertified copy is filed with the county budding inspection LOCALITY � NEAREST / n
department IE PLS CROSS ST v
Date Applicant NEAREST DISTRICT N GROUP TYPE P SSED Y
CROSS ST O — CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGALd
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SECOND LOCAL
NO OF SLOGS
(This section need not be completed If the work involved TRACT /-7/ NOW ON LOT ,f USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) /
SIZE OF LOT USE OF/ 0 EXISTING BLDG/�CSIptlp/ !_�,
I certify that in the performance of the work for which this t T' U
permit is issued I shall not employ any person In any manner OWNER �gy� �r �}iVTf1 J'CVLf—
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP o
ADDRESS
Date ApplicantT ~
L�-1J
NOTICE TO APPLICANT If after making this Certificate of CITY ? CW NOL�4r ,�if7-"cam' 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 ❑ GEOINSPECTION No Spec Knowl
deemed revoked LO
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT EJ (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
effect IL, 1AJ PARKING
SPACES REO D D PROVIDED
License Number Lic Class
_ LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a FROM TO
licensed architect or a registered professional engineer SIZE OF No OF I INSPECTOR s
acting in my professional capacity (Section 7051 Bus EXISTING BLDG STORIES SIGNATURE
mess and Professions Code) FINAL�APPROVAL
PRESENT USE OF BUILDING l/
Lic or Reg No Date i
M&*4_PAC�
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS {
'6.07 rl
ON LOT AND USE 7 ITEM:
I hereby affirm that I am exempt from the Contractorsl�l 1 t cr
License Law for the following reason (Section 7031 5 Busi TILT �0 0• F..I
ness and Professions Code) No PARKING IT / C-
SPACES PROVIDED ��ILL.( 0• 114
❑ I as owner of the property will do the work and the u(R� r
structure is not intended or offered for sale (Section CHEF s - �•�l
7044 Business and Professions Code) t '
PROPOSED USE OF BUILDING remits' /.t.7Z'rx, t •ill
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency p� �� lQK Hd r roa 0V
for the performance of the work for which this permit is 0- 171 ,— r-J x„ 1`4 d{![Ir-000 11/ '3
issued(Sec 3097 Civ C) rs- CD S
Lender s Name [c1 ',^�i t 6 p�1� 1..
PROPOSED MAX pCC GI "-'x; i f,+ •
Lender s Address
PERMIT FEE GI ...,.1 j
I certify that I h ve read this apphratlo a d state that the C:i fn 1
above informa o is correct I agree to c p y with all County ISSUANCE FEE �� I
above
an State laws relating to ding cons ruction + I
and hereby horize representatives o this Cou o enter TOTAL FEE w
upon thea 6v menSty nspec oses I I
REVERSE FOR EXPLANATORY LANGaGt7
O
•
lgnature of Permit e Date - ..p 0 � C'