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Home My Public Portal About5636 GRACEWOOD AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 876(2$0) MISCELLANEOUS A P P L I CAT 10 N I hereby sties" that I have a certificate of consent to self COUNTY OF LOS ANGE � BUILDING AND SAFETY DIVISION Uvure, or ■ certificate of Workers'Compensation Iruurance,or �� y ■certif[Kpopy ttVreof(Sec. 3800,Lab.C.) �/ Policy No. Company FOR APPLICANT TO FILL IN ...... <0 C-1162,649 O ❑ woDR[s/ Certified copy is hereby furnished. BUILDING LOCALIT ❑ ADDw[a/ 6 b r4 ,�'Woc�sU '� Certified copy Is filed with the county building Inspection � N[wR[■T P LOCALITY Txln�/E' c.., / ,////- de artmane. /ALL CRO/1 /T. I'✓ V�.r DatO Applicant N[AR[■T DUTR T NO. GROUP TYP P a ■Y ` CRO// ■T. LiU 6).4 A CON/T. CERTIFICATE OF EXEMPTION FROM WORKERS' LKGAL . (� COMPENSATION INSURANCE DI[/CRIPTIOM I LOT NO. -LOCK rA� �� HIGH rAY RO. /TAT[ MAJOR 5K OND LO L NO. OF ■LDG/. ^ (Till aectioII need not beCOIDppleted if�the woIk hrvuhrod TRACT NOW ON LOT 2 U/[ zDN[ /P[GIRL CONDITIONS (},� by the permit Is for one haadred dolls" ($100) or leu.) ■rz[ or LOT (0(7r d [x�/r Na ■LDa.,WVwC � I certify that in the performance of the work for whlch this 0 permit is Issued, I ahnll not employ any person in any manner OWN[R so as to become subject to the Workers' Compensation Laws. MAIL f mON s OCCUPANCY GROUP lis "DDR13- Date-Applicant Z NOTICE TO APPLICANT: If, after making this Certificate of cITY Q� No-.r-.L-L.. r� OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must.forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisloru or this permit 1haB be TRAIL[R Ua[ G[OLOaY IN/PiCTION deemed revoked. ❑ ❑ No Spec. Knowl. ❑� fPanic Devices LICENSED CONTRACTORS DECLARATION occurwNcr IN/P[cn r I hereby affirm that I am licensed under provisions of Chapter /AFISTY P[RMIr ❑ 9 (commencing with Section 7000) of Division 3 of the Bust- (LIST rt[M/ ■¢Lov) No. of /xlrsEl news and Professions Code, and my license Is In full force andI PARKING. effect. , ■PAc[s R[q'D E== PROVID[D License Number Lic.Clan LIMITED TIME USE Contractor Date DAT/ DAT/ FROM. TO. ElI am exempt from the licensing requirements as 1 am a .1censed architect.or a registered professional engineer slz[ OF NO. OF IN/PKCTOR'■ acting In my profeWonal capacity '(Section 7051, Bus- [xlsrlNG BLDG. ■TORI[■ /Ia NATUR[ Ineasand ProfmAortsCode). PRKSKNT U/q OF BUILDING FINAL APPROVAL c:.� Lic.or Reg.No. Date f�S HOME OWNER-BUILDER DECLARATION NO. a BUILDINGS ON LOO T AAND MD US[ I hereby affirm that' I am exempt from the Contractor's -2 47 Q 6 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING # o 0 0 0 2 2 ■PAC[■ PROVID[D . 09 1, as owner of the property, will do the work and the • structure Isnot intended or offered for sale (Section .2e'Db1,00 7044, Business and Professions Code). PROPO■[D U/[ OF ■WILDING ./ pip 6 1. 006 CONSTRUCTION LENDING AGENCY dl'lI 0—8 1 I hereby affirm that there Is a construction lending agency for the performance of the work for which ihls permit Is Inuad(Sec'. 3097,Ch.C.). Lender's Name PROPO■[D MAX. OCC. Lender's Address PERMIT FE[ 67 I certify that I have read this.application and state that the above information Is correct.I IEEuwnce FEE e to comply with all County✓fie P ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE �� up �thbole m tl e�L property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE l An y y� tore of Permittee. Date i WORKERS'COMPENSATION DECLARATION CE 875(114) M ISCELLANEOUS APPLICATION CE 878 I &,by affirm`�at I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION hours or a, cate of Workers'Compensation Insurance,or a cert�t3ed Vpy thereof(Sea 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDR/// FICertified copy is hereby furnished. ■uILDIXG D LOCALITY -DDR[// dCertified epartment Fy is filed with the County building inspection LOCALITY Q / '� N[AR[/T V t CROSS WT. r[ /6D ■Y Date /vl Applicant H[ARL/T DI/TRI VO. [_�;�'ry X/T / rR CRO■C ■T. Yi/ CO .V CERTIFICATE OF EXEMPTION FROM WORKERS' L[6AL COMPENSATION INSURANCE D[■CRIPT ION LOT NO. ■LOCK HAS HIGHWAY Xo. (ciRCli) /TAT[ YAJOR ■[C D LOCAL NO. OF ■LD 61. (This section need not be Completed if the work Involved TRACT NOW 1, LOT U1 ZDX[ ■P[CUL CONDITION■ by the permit L for one hundred dollars ($100) or leas.) , u/[ or BIZ[ OF LOT RXIGTIHG BLDG. I certify that in the performance of the work for which this o permit L Ltued,I shall not employ any person in any manner o.N[R so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP / o ADOR[■/ Date Applicant g NOTICE TO APPLICANT: If, after making this Certificate of arty No. OCCUPANT LOAD Exemption, you should become subject to the Workerd APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- with comply with such provisions or this permit shall be TRAIL[R U.[ ❑ GKOLOGY INSPECTION ❑ No Spec. Know]. El deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY IN/P[CTION ❑ Panic Devices El I hereby af8mn that I am licensed under provisions of Chapter /Ap-x" r[RYrr ❑ (LIST rr[Ys ■aLor) 9 (commencing with Section 7000) of Division 3 4f the Bus!- NO. or [a1T/ nets and Professions Code,and my license is in full force and �• PARKING R[q'D PR OVID[D 8-6 .� . Liken'°Number Lia Class LIMITED TIME USE Contractor Date DAT/ DAT= ❑ I am exempt from the licensing requirements as I am a rROYI TOI licensed architect Or a mgWered pTotbasional engineer R[ OR S STWJ�! Xo. OF I�,u[CTu1Re= acting in my professional capacity (Section 7051, Bus- [XI/TING BLDG.G. /TORI[/ ineuand ProfessionsCode). FINAL APPROVAL Lla OI Reg NO. DatePR<L[XT U1[ Or BU ILDIn6 i C `�y HOME OWNER-BUILDER DECLARATION NO. Or [XI/TING BUILDING/ ON LOT AND U/[ N I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 S, Buri- — IF- 1-49arFsr Pwcm 17 9 7„0 A ness and Professions Code): NO. PARKING • • • • I, as owner of the property, will do the work and the ePAC[■ PROVID[D #. 3.Q structure is not intended or offered for sale (Section 11 • e80,50 7044,Businm and Professions Code). • Q 5 PROPO■[D U/[ or BUILDING CONSTRUCION LENDING AGENCY T I hereby affirm that there is a construction lending agency for the performance of the work for which this permit L Lsued'(Sea 3097,Civ.C.). Lender's Name PROPO■[D MAX. OCC. Lender's Address I certify that I have read this application and state that the P[RMIT FKa W. above information L correct I agree to con ly with all County IssuANCK r[[ f ordinances and State laws relating to bu construction, and hereby authorize representatives of this ounty to enter TOTAL Pae upo a mentio perty for inspection purposes � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Data