HomeMy Public PortalAbout10904 FREER ST_Miscellaneous__ wORKER3'COMPENSATION DECLARATION
CE 876 (114) MISCELLANEOUS APPLICATION
CE 876
I hereby affirm thVLII have a certificate of consent to pelf COUNTY OF LOS ANGE BUILDING AND SAFETY DIVISION
t;ulrre, or a-certiflcacat of Workers'Compee nsation Insurance,or ,
a certtW copy thereof(Sec_ 3800,Lab.C.).
Polity No. Company FOR APPLICANT TO FI LL IN BUILDING
•` ADDRK// / Q
Certified copy is hereby furnished. BUILDING b9 !JT LO CALrtY
ADDRKaS
0 dortifI d copy is ed with the county building inspection LOCALr Y L '_ NKARK■T
_ CROSS RT.
Date Applicant MKARKIT DISTRICT No/// our TYPK KSSKD ■r
CRO/i ■T.
CERTTFIGAT'E OF EXEMPTION FROM WORKERS' LK GAL
COMPENSATION INSURANCE DK/CRIPTION LOT NO. ■LOCK MwP HIO XWAT
No, (C-D,,•m) i'rATK MAJOR ■K CO ND LOCAL
NO. OF ■LDGi.
(This section need not beCompleted if the work Invohod TRACT NOW ON LOT USK ZONK RPKCIAL CONDITION■
by the permit L'for one hundred dollen (5100) or lea.) USK OF
I cm-Iffy that in the performance of the work for which this SIZK of Lor Kx1iTING BLD a. CD
CD
permit is issued, I shall not employ any person in any manner OWKKRy, E T'
so as to become subject to the Worken' Compensation Laws OCCUPANCY GROUP
MAIL
' AD DR KI■ O {C-7
Date Applicant
NOTICE TO APPLICANT: Lf, after TKL OCCUPANT LOAD
making this Certificate of crtY � No D-
Extmptlon; you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLI ATION FOR EXIT HARDWARE:
with coipply with such provisdons or this permit shall be TRAILKR USK ❑ azoLoaY IN/PKc-rloN ❑ No Spec. KnowL
deemed revoked.
LICENSED CONTRACTORS DECLARATION occurwwcY IN■rKCT1oN Panic Devices El
I hereby Affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Buri- ■wFKry PKRMrt ❑ (LIST rrums ■KLow) No. of Kxrts
ma and Professions Code, and my license is In Rrll force and
PARKING RKQ'D ROVID KD
License Number Lie. Class y _ LIMITED TIME off•i*
Date ate DATK sau DATL
F1I am exempt from the licensing requirements as I am a FRDMI TDI " T
licensed aichhoct or a registered professional engineer ■IZK ofNo. OF cTOR'■
acting in my professional capacity (Section 7051, Bur lxurrlNa BLD G. 1TORlt/ as(,• uses c
In=and ProfessionsCode). FINAL APPROVAL
PR KIK NT USK OF BUILDING /,..� i! .�C
Lia or Reg.No. Date Y {w
C$WkT _4;)�.
HOME OWNER-BUILDER DECLARATION NO.of KXIBTING ■UH-DINGS Cifi
ON LOT AND USK
I hereby afflrm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Buri- 000a—U031 r/34i/44
nems and Professions Code): NO. PARKING
I, as owner of the ro /PACKS PROVIDKD 5422 1 Am Q'17
p arty, oven do the work and the U��`'
structure is not intended or offered for sale (Section
704-4,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPO■KD USK OF BUILDING
I hereby affirm that there is a construction lending agency "
for the performance of the work for which this permit is
fasuod(Sea 3097,Civ.C.).
Lender's Name
PROPOIKD MAK. OCC.
Lender's Addrems '
I certify that I have read this application and state that the PERMIT FR4 p
above information 1s correct I agree to comply with all County ISSUANCE PKK
ordinances end State laws relating to building construction
and hereby authorfae reprementativei< of this County to entet TOTAL FHE
upon the above-mentioned property for inspection purposes.
�i
SEE REVERSE FOR EXPLANATORY LANGUAGE
S taro of Permittee Data