HomeMy Public PortalAbout10941 FREER ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 7E e�(2�0) MISCELLANEOUS APPLICATION
affirm that I have ■ certificate of concent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY'DIVISION
r a certificate of Workers'Compensation Insurance,or
ad copy thereof(Sec.3800,Lab.C.)
No. CompanyUILDIN
FOR APPLICANT TO FILL IN ■DDNKSS 5P �el
-
A
Certlfled copy is hereby furnished. ■u1LDIN0 LocwLrrr
ADDR[■f
Certified copy is filed with the county building InspectionN[wR[■r
department. LOCALITYtjl 3- CIt OS■ ST.
Date Applictnt N[AR[ST DISTRICT NO.TGROUP TYr[ �PROCK [D SLX
CR0■■ ■T. [ �''�' S-i0 p/ CONaTr /
CERTIFICATE OF EXEMPTION FROM WORKERS' L[UAL r
COMPENSATION INSURANCE D[scRIPTION LOT No. K rAe Q HISHWAY
�Q (c lw cies) STAT[ MAJOR f[COND LOCAL
(This
OF 1SLD6a. RD. - iL
&action need not be completed if the work involved TRACT A,,LJ1?f NOW ON LOT US[ZONE SPKCIAL CONDITIONS O
by the permlt is for one hundred dollars ($100) or lea.) U
■Iz[ of to . OX S-11 1Q1PG[x rrlNaUSK Orr iiDo� F,}q� 1
I certify that in The performance of the work for which this - lr
permit is Issued, I shall not employ any person in any manner oarn[R
to as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUPF
DADDRESS `~ LU
Date Applicant fA
a.
NOTICE TO APPLICANT: If, after making this Certificate of clTY No.T[L.p�p7— OCCUPANT LOAD 2
Exemption, you should become subject to the Workers' r
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAIL'[R US[❑ a[oLoar INee[CTION No Spec. Knowl. ❑
deemed revoked. Panic Devices ❑
LICENSED CONTRACTORS DECLARATION occurwNcr rNar[anoN
I hereby affirm that 1 am licensed under provisions of Chapter ■AF[TY P[RMrr I (Liar ITEMS ■[LOW) no. of [xrTa
❑
9 (commencing with Section 7000) of Dion 3 of the Buil-
ivis
ness and Professions Code, and my license L In fall force and
r AR KING.
effect.
r (PACKS R[Q'D rR OVID[D
License Number LIc..Clam
LIMITED. TIME USE
Contractor Data DAYS DAT/
❑ I am exempt from the Licensing requirements as I am e
licensed architect or ■ registered professional engineer srza OFNo. OF,
f INSPKCTOR'■
acting in my professional capac(ty (Section 7051, Bus- [xIsTINa ■LDD. &TOR F, /I6NAT
meas and Professions Code). FINAL APPROVAL S
rR[■[NT Uf[ OF ■UILDIN6
Lic.or Reg.No. Date P
8 A ME OWNER-BUILDER DECLARATION no. of ANDXXISUSKING 2 3 0.BUILDINGS
H7.
0 ON LOT AND f[
I hereby affirm that,I ■m exempt from the Contractor's o o a 0 3 0
License Law for the following reason (Section 7031.5, Busl-
new and Professions Code): NO. PARKING �0 0 8 Q 5 0
SPACESrROVID[D
❑ 1,•as owner of the property, will do the work and the o I o -.8 (1 0structure Is not intended or-offered for sale (Section is
7044, Business and Professions Code).
PROPON[D usa oIr nUILDIND 06 22-83
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is ■ construction lending agency
for the performance of the work for which this permit Is
issued (Sec. 3097,Civ.C.).
Lender's Names PROPOSED MAX. OCC.
Lender's Address �
PERMIT PH6 '`/� n
I certify that I have reed this application and state that the
CE
above information is correct.I agree to comply with all County ISSUANCE Fl3 .r
erdlrlances and State laws relating to building construction, �l —9 —��—
and her authorise representatives of this County to enter TbrwL Fes V rf o�
upo above-mentloned property for Lnspe ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE (�
Signature of Pffneat, Daf a f