HomeMy Public PortalAbout9716 GARIBALDI AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN ■UILDIMG
AD DR RSI f..i
Certifled copy is hemby furnished- BUILDING 1 ��
ADDR[■S LOCALRY
Certified copy L HlOd with the COanty building inspection LO CALR �T��j�CL`� (Af / /�� NKA:[/T
ant.
Date Applicant M[wR[ar �� �Sr DISTRICT No. o uP TYP[ oc SSUDINY
_CROSS ■T. J' CONST
CERTIF'IGATE OF EXEMPTION FROM WORKERS' LXGAL L� v
COMPENSATION INSURANCE D[SCRIPTION LOT NO. ■LOCK —b.- (CI CLi) STAT[ MAJOR ■[GOND LOCAL
NO. OF BLDGS.
(This section need not be Completed if the work fnvotred TRACT NOW ON LOT US[ ZOM[ ■P[CLAL CONDITIONS
by the permit is for one hundred dollar (;100) or less.) US[ of /V
I certffy that in the performance of the work for which this Srz[ OF LOT [xI■TING ■LD
permit is issued, I shall not Ont Y any person any manner ow-NKR _ (jiLl�lRf✓ S�
so u to a subject to mafter
tion Laws. //MAIL ''��� S OCCUPANCY GROUP _ �
wDDR[e■ /&/ 'xWJ�L�j G p
NOLLA
TICE TO LICPANT: akingthis Certificate of CRY l_J rTioL .�J fsQ OCCUPANT LOAD N
Exemption, you should become subject to the Workers'
Compensation proyisions of the Labor Code,you mast forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall beTRAIL[R U/[ ❑ G[OLOGY INSP[CTION ❑ No SW. KnOwl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSrKaTION ❑ Panic Devices
I hereby affirm that I am licensed under pprrevisions of Chapter
9 (commencing with Section 7000) of Dfvltion 3 of the gust ■wF[rY r[RMR ❑ (ueT R[Y, ■¢Lot)
NO. OF [XR•
news and Professions Code,and my license is In full force and
effeCL - PARKING
SARs IN [ D V
Rq' PROID[D
License Number 7L iia Clan LIMITED TIME USE
Contactor Date DAT< DATt
I am exempt from the licensing requirements as I am a '�OY1 TD
licensed-architect or a registered profdsslonal engineer Sa[ OFNo, of INSP[cTOR'■
acting In my professional capacity (Section 7051, Bus- [XISTINa BLDG. ST0Rl[s SIGN TUR[
inand Professions Code).
FINAL APPROVAL
PR[S[NT US[ OF BUILDING DvY7(O
Lir-or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. of [XISTING BUILDINGS
ON LOT AND US[
I hereby affirm that I am exempt from the Contactor': `{'T'T
License Law for the following reason (Section 7031.5, Bust- ell J -13017 p c
new and Professions Code): NO. PARKING
as owner of the property, will do the work and the s.wa[s rleovlD[D j TT
structure is not intended or offered for sale (Section
7044,Busfnen and Professions Code). TOTAL 80 50
CONSTRUCTION LENDING AGENCY PRoros[D us[ of BUILDING
I hereby affirm that there is a construction lending agency l �T
for the performance of the work for which this permit is
Issued(Sea 3097,Civ.a).
Lender's Name I � 3/23/99J�3/99
PR OP OS[D MAX. OCC. �JLP!I.J—I�I,}LI j,
Lender's Addren {
certify tify that I have read this application and state that the PERMIT PHS ?� � 1 s_��ti t{■�
above information is correct I agree to comply with all County ISSUANCE PSE
ordinances and State laws fatfng to buil construction,
hereby authortz re tatives of this County to enter TOTAL. Fee
o e do o perty for inap n pu osea
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa of Permittee Date