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WORKERS'COMPENSATION DECLARATION 76 976(2 80) MISCELLANEOUS APPLICATION
I herby ■fnrm that I have ■ certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified cbpy thereof(Sec. 3800,Lab.C.)
Policy No. Company FOR APPLICANTTO FILL IN ■uILDInG
ADDR[//
❑ Certified copy V hereby furnished. BUDRDIE
LING LOCALITY
ADSS -
❑ Certified copy is filed with the county building Inspection NK-AR[■T
department. LOCALITY CROSS ST.
Date Applicant NEAREST , 1 DISTRICT NO. GROUP TYra rROC ESSED ■Y
CRO/■ ■T. Vd•v CON■T.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. �� ]BLOCK YAC }
�{,�� n o.` (Clec Li) STATE MAJOR SECOND LOCAL 8
(TILis NO Or BLDG/.
aOCtiOR need ROY UO CO�pleted II the IV'OIk iDVOiVOd TRACT 5.JV3 NOW ON LOT ?j UST ZON[� SPECIAL CONDITIONS
by the permit L for one hundred dollars ($100) or lea.) r r u/E or 8
sitz Or LOT 5th X 1`�L7 Exi/TING BLDG.
I certify that Ln the performance of the work for which this O
permit Is Issued, I shell not employ any person In any,m■nner ovNER �A01zI 14 E4!:] U
so as to become subject to the Workers' Compensation Laws. MAIL 3_146. I n �^ A ���� OCCUPANCY GROUP IL
ADDRE/■ �j-Y-Y iGiLG�'1�I Yti'✓o"va+�+
Date Applicant �` ,,,�
NOTICE TO APPLICANT: If, after making this Certificate of CITY ls1z��7(UtZcL No. (S)��—vi Gs OCCUPANT LOAD
Exemption, you should become subject to the Workers'
I Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with Comply with such provWQ❑s or this permit ■hall be TRAILER USE GTOLOGY INSPECTION
deemed ravoked. ❑ No Spec. KnowL
LICENSED CONTRACTORS DECLARATION occuPwrcY INSPTGTION ❑
Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO, Or EXITS ❑
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license Is in full force and PwRKING.
effect. ■P*CE■ REq'D PROVIDED
License Number Lie.Clan
LIMITED TIME USE
Contractor Data DATM DAT.
❑ I am exempt from the licensing requirements as I am ■
licensed architect or a registered professional engineer BIZ[ OF /J 1 I NO. OF AC INSPECTOR'■
acting In my profeeriional Capacity (Section 7051, BUJ- EX Ia TI NG DLD G. Z K 3 STORIS■ { _ SIG NATUR■
mess and Professions Code). rRE/ENT USE of BUILDING FINAL APPROVAL
Lie.or Rek.No. Date
ds
HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS K e33 g� •_ --
ON LOT AND USE �'??��'] {r
IL
33V! 9v.C
I hereby affirm that• I ■m exempt from the Contractor's
License Law for the following reason (Section 7031,5, Busi- II�L 1 ITEM
nd Professions CodNO. CARPING
Coda): ■rwcE■ PROVIDED !TOTAL 93 - 00
21, as owner of the property, will do the work and the
rtructure Is not intended or offered for sale (Section DE X 9-7.oil
7044, Business and Profeulons Code).
' PROPOSED USE OF SUMMING \A .OI• 1f sL1�7 1 CNARI •C0
CONSTRUCTION LENDING AGENCY A, 61- � YV� IJL��T�fJ`G
I hereby affirm that there If ■ construction lending agency 0,
for the performance of the work for vKhlch this permit is Z _3/4 ( (�-1�Q1 5'/17/91
issued (Sec. 3097,Civ.C.). �6
rL Lender's Name PROPOSED MAX. OCC. (004 1 > 3:5"1
Lender's Address PERMIT FEE
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County ISSUANCE FEE ,
ord ceJ end State laws g to bulldlns construction, T-TAL FKK
e❑ er y authorise pr rat oC thLs County to enter
0Y.bovo-glen y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
4 —ce W.0
Slgnatur of Permittee Data