HomeMy Public PortalAbout10708 FREER ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76N1444 M I SC E L LA N EO U S APPLICATION-_-
I hereby affirm that I have srcertifT pe of consent tself CE 875 (11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certifii;ate of Workers'Compensation Insurance,
e,or
a certified,copy thereof(Sec. 3800,Lab.C.).
Policy No. -_Company FOR APPLICANT TO FILL IN BILDING
Certified copy is hereby furnished. BUILDING LOCALITY
ADDRESS ADUDRESS
El Certifiech"copy is filed with the county building inspection
department. LO CALITYr IA n L �f �w / NEAREST
�/( L. C/ CROSS ST.
Date Applicant NEAREST
��� � ��� DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST. 7y,�O ( CO �i//J'
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v O
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY Gt P
NO. (CIRCLE) AT MAJOR SECOND LOCAL
NOOF LDGS.
(This section need not be completed if the work involved TRACT NOW. ONBLOT USE ZONE SPECIAL CONDITIONS
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 �p L - ' O_
permit is issued, I shall not employ any person in any manner 0 W N E R 7_,6/: U T_A�
,L/ A /p
/- Co L,0,4/ s�
so as to become subject to the Workers' Compensation Laws. /J 3
MAIL w /� OCCUPANCY GROUP
ADDRESS CT ,09 Ie44 S'7—
Date Applicant �
TEL d
NOTICE TO APPLICANT: If, after making this Certificate of CITY-7r-141/7/ LC C.,7- No. '�S'' ��9� OCCUPANT LOAD
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 provisions Or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl,
deemed revoked. P
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT
9 (commencing with Section 7000) of Division 3 of the Busi ❑ (LIST ITEMS BELOW NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. - PARKINGREQ'D D PROVIDED D
/ SPACES
License Number Lic. Class yy'�'G/
LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE
inessandProfessions-Code). .. -rc FINAL APPROVAL -
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �A1
ON LOT AND USE / J/
I hereby affirm that I am exempt from the Contractor's L !llVVV77///
License Law for the following reason (Section 7031.5, Busi-
ness_and Professions Code): NO. PARKING +y _
I, as owner of the property, will do the work and the SPACES PROVIDED (:_ 'a4
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
fj`r_
CONSTRUCTION LENDING AGENCY PROPOSED use OF BUILDING i
I Hereby affirm that there is a construction lending agency lC �, 4:� 3
for the performance of the work for which this permit is is '4s4:`
issued(Sec. 3097,Civ.C.).
Lender's Name -!,-�
PROPOSED MAX. OCC.
GE
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEEi E-i Egli t i fi'
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE O7� I++_+ _ it l
upon the above-mentione�ope ty for inspection purposes.
y- ,` 9� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date