HomeMy Public PortalAbout9115 GARIBALDI AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE Sia(2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have ■ certof consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
iruure, or a certificate of Workers'Compensation Iruuranca,or
■certlfled copy-thereof(Sec. 3800,Lab.C.)
.Policy No. Company FOR APPLICANT TO FILL IN ■UILDIN6 /
ADDRES■
❑ Certified copy is hereby furnished. BUILDING
/� r ��(„��' LOCALITY
F-1
V
Certified copy 6 filed ADDRESS ed with the county building inspection r— N[AR[Sr
department. LocwLITY —�.�(�N` / cNOS■ ■T.
Date Applicant N..R[.T /� Y ( L DISTRICT ryp. a UP rvr[ rRPC ■
C.O.. ■T. /9`/�/ / / / �iS �� CONST.
CgRTIFICATE OF EXEMPTION FROM WORKERS' LUGAL I(�
COMPENSATION INSURANCE D[sc RIPTION LOT No. Z �� ■Loc /( �0 �A� H.aH�AY >-
Ho. (c.wc Lt) STAT[ MAJOR ■[CO LOCAL d
//��r�h1,i�s� NO. OF ■LDaS. /1
l \++++� feCflOn need not b0 Completed if the P'OIY involved TRACT s D NOW ON LOT Z Us[ ZONA SPECIAL CONDITIONS }Vr
by the permit is for one hundred doIlars ($100) of lq%L) us[ of
BIZ[ OF LdT O r 7 [x11TtNa BLDG.
I certify that In the performance of the work for which this O
permit is issued, I shell not employ any person In any manner OWNER — p (r V A
so as to become subject to the Workers' Compensation Laws. MwIL ^ OCCUPANCY GROUP i tis
Date Applicant
/ Y 7A •l-1 /3 D/ �
NOTICE TO APPLICANT: If, after making this Certificate of cI /2!� G!� rTio� _PS-_
`-7 3 l T OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compansatlon provisions of the Labor Code, you must forth- APPLI ATION FOR EXIT HARDWARE:
with comply with such provisions or this permit &hall be TRAILER UY[ a[OLOSY INSPECTION
deemed revoked. ❑ ❑ No Spec. Knowl. O
OCCUPANCY INSFRCTION Panic Devices
LICENSED CONTRACTORS DECLARATION L7
I hereby affirm that I am licensed under provisions of Chapter ■AFKTY PER&sIT ❑
9 (commencing with Section 7000) of Division 3 of the Bwl- (LIST ITCIrs BELOW) No. of Exrr■
ness and Professions Code, and my license Is In full force and G CrwRlclNa.
effect. REq'D E==
rR OVID ED
License Number Lic.Class `�``�� V( A) /� (i�r�� SPACES
Contractor Date /v0 �'> c,%�c�,t/ ,q �`G � ' ��, LIMITED TIME USE
DAT& DAYS
❑ I ■m exempt from the licensing regiltrements as I am ■ rwor. To.
licensed architect or ■ registered professional engineer ■Iz[ or No. or INSPECTOR'S
acting In my professional capacity (Section 7051, Bur EXISTING BLDG. '3 G STORMS S NwTUR[
iness and Professions Code). FINAL APPROVAL
aR[S[Nr USE of■ulLnlNa
Lic.or Reg.No. Date
/+ G-71K tis b M
HOME OWNER-BUILDER DECLARATION No. of ExlsnNG BUILDINGS
ON LOT AND Us[
I hereby affirm that, I am exempt from the ContractoF's �r•�i
23885A
License Law for the following reason (Section 7031.5, Bust- fi
ness and Professions Code): NO- PARKING # • • • •���,
SPAC KS PROVIDQD
❑ I, as owner of the property, will do the work and the
structure is not Intended or offered for use (Section
_ .I • • 8C150
7044, BusInan and Professions Code). PROPOSS:D USE OF BUILDING • • • 8 Q 5 0 2i
CONSTF,UCTION LENDING AGENCY // i / /��� �r �,Z•� 8 b
I hereby affirm that there Is.■ construction lending agency L• �C
for the performance of the work for which this permit Is
Issued(Sec.3097,Ctv.C.).
Lender's Name PNOPOS[D M". OCC.
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 FSH
Ord antes and State laws re ating to buildln� construction, TOTAL FE[
an hereby authorise representatives of this County to enter O
u n e a o- entl nod property for Inspec on pupposft. SEE REVERSE FOR EXPLANATORY LANGUAGE
9.44 / pis
Signa mlttee Da
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� may