HomeMy Public PortalAbout5634 GRACEWOOD AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 876715 (11-84) M I SC E L LA N E O U S APPLICATION
� � CE
I hereby af1crm that I have a certificate of convent to COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
hulrre, or n certificate of Woricerd.Compensation Insurance,,or or
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN MDDR■U ILDICR/INOfi
Certified copy Is hereby furnished_ ■UILDING J}�3/ AGG c � LocwLlrY
ADDRIC■■ Cr
Certified copy Is filed with the county building Inspection LOCALITY NKARIC■T
department, AAfCROSS ST.
Date Applicant NICAR t/T DIiT�T 4�1/ CAR Oljp TYrt PROC t DY
CROSS ■T. �` COH/T.�
CERTIFICATE OF EJL'EMPTION FROM WORKERS' LICGAL
COMPENSATION INSURANCE DIC■CRIPTION LOT NO. ■LOCK w� HMO Ar
NO. (CIRCL ) RTATIC MAJOR ■ICCO LOCAL
NO. OF ■LD6/.
Section need not be COrrlpp�eted If the wort involved TRACT NOW ON LOT U■ ZONIC /PICCIAL CONDITION/
by the pemilt L for one hundred dollars ($100) or less.) USX OF . r
I cmtffy that in the performance of the work for which this RIIIC OF LOT ICXI/TING ■LD G.
C:3
permit L issued, I shall not employ any person in any mann OWNICRMIN _ AJ .fLJ
s�
so ss to become subject to the Workers' Compensation Laws MAIL JJ A r�/ OCCUPANCY GROUP ce
Date Applicant ADDR IC■/ ( C.ACa4
NOTICE TO APPLICANT: If, after making this Certificate of crrY TIL. � 4/ OCCUPANT LOAD °
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation proTWons of the Labor Code,you must forth
with comply with such provisions or this permit shall be TRAILICR URIC ❑ GICOLOGY IN/PSCTION ❑ No Spec. Know].
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY IN/PICCTION Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Secdon 7000) of Division 3 Of the �} /AFICTY PICR YIT L] (LIST fTICY■ IIC LOW
HO, OF ICXIT/
nese and Professions Code,and my license Is in Rill force and
effect ) PARKING RICgD pROVID ICD
/PACIC■
License Number Lia Cls„ 3• LIMITED TIME USE
Contractor Date D AT t DAT=
ElI am exempt from the liceuaing requirements as I am a FROMI TD,
licensed architect or a registered proibssional engineer /IZIC OF Ho. OF IH■PICc•roR'■
acting In my professional capacity (,Section 7051, Bus- it TING BLDG. 2.7 v /roR1ICR SIGN TUR6
inesvand ProfesslonsCode). FINAL APPROVAL
PRIC/ICHT 016 OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. of XXI/TING BUILDINGS
ON LOT AND URIC
I hereby affirm that I am exempt from the Contactor's
License Law for the following ramn (Section 70315, Bursa- 11 .0 G 7 A
nets and Professions Code): NO. PARKING
❑ I, as owner of the property, RPw CIC■ PROVIDICD
p army, will do the work and the # ° ° ° �• 3 0
structure is not intended or offered for sale (Section 1 u °'8 G 5 0
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPosICD usIC of BUILDING . D D 80,506
I hereby affirm that there is a construction lending agency I G 2-7"-8 8
for the performance of the work for which this permit Is
Issued(Sec. 3097,Civ.C.).
Lender's Name
PROPO/ICD MAX. OCC.
Lender's Address
I certify that I have read this application and state that the MRMIT FE[
above information is correct.I agree to Compply with all County I88UANCIC Flit ,S
ordinances and State laws rel.% to bnild12 construction, O
and hereby authorize representatives of this ounty to enter TOTAL FIC[
upon the above-mentioned property for inspection purposes.
���— SEE REVERSE FOR EXPLANATORY LANGUAGE
S jture of Permittee Data