HomeMy Public PortalAbout5638 GRACEWOOD AVE_Miscellaneous__ 1
WORKERr4'COMPENSATiONDECLARATION wA
CE875 (11$4) MISCELLANEOUS APPLICATION
CE 876
I eereby affirm that I have a certificate of consent to self COUNTY Off' LOS ANGELES BUILDING D S DIVISION
insure or a certificate of Workers'Compensation Insurance,or
a cert�fied copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN MA U0 u ILDR DEIINfG
Certified copy is hereby furnished. BUILDING ,\�
ADD R[// w LOCALITY
❑ departmenipy is ffied with the county building inspection LOCALITY fes• NKDISrZCT
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Date Applicant NEAREST , r TYPE OC ■■[D SY
CROSS ST.
CONST.CERTIFICATE OF F.xEwnON FROM WORKERS' LEGALCOMPENSATION INSURANCE D[SaRIPTION LOTNO. ■LOCK HWHWAY
(CTR CL!<I ■TAT[ MAJOR R[COND LOCAL
//�-�,,���� NOor ■LOCI.(This section need not be Com Ietedif the work involved TRACT 3 NOT■ ON LOT CONDITION/
by the pemrh Is for one hundred dollen (;100) or Ims.) uI[ or
I � that In the performance of the work:for which this ■a[ or LorjZk% [xurlNG ■LD G.
permit is Ismed, I shall not employ any person In any wanner OWNER $ � o
s�
so as to become subject to the Worker-s' Compensation Lava OCCUPANCY GROUP _ 3 ae
.AIL
AD DR GSI ��
Date Applicant 1
T[L.
NOTICE TO APPLICANT: If, after making this Certificate ofHo. � OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: -'
Compensation provisions of the Labor Code, you must forth
with Comply with such provisions or this permit &hall be TRAILER US[ GEOLOGY INSPECTION
E] El No Spec. Knows.
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (Commencing with Section 7000) of Division 3 of the BU&i- SAFETY PERMIT ❑ (LIST IT[./ BELOW)
NO. Or EXIT■
nen and Professions Code,and my license is In full force and i
effect PACKS
R[q'D rROVIDtD
� t 1rACE■
License Number Lie. Clara
,,+,.toLIMITED TIME USE
Contractor Date DAT■ OAT■
F1am exempt from the licensing requirements as I am a rRDrl TOI
licensed architect or a registered profbasional engineer SIZE Or no. or IN■r[cTO R'•
acting to my profesdorlai CapaCfty (Section 7051, Bua- EXISTING ■ILD 6. STORIES ■ TUR[
ties:and Professions Code).
PRE■ENT U/[ OF BUILDING FINAL APPROVAL
i
Lic,or Reg.No. Date
kxyllf,A&
HOW OWNER-BUILDER DECLARATION NO. Or EXISTING BUILDINGS
ON LOT AND US[
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Buil-
nm
ustnoes and Professions Code): NO. PARKING
I, as owner of the pm , will do the work and the SPACES PROVIDED 1 `
structure is not Intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCI`ION LENDING AGENCY PROPOSED-USK of BUILDING
�54,QOA
I hereby affIrm that there Is a construction lending agency - - -
for the performance of the work for which this permit Is # o'.a a • Q
issued(Seo.3097,Civ.C_).
Lender's Name 1 P.0-8 Q-5 D
PROPOSED MAX. OCC. < •.
Lender's Address ' ' a 0'08 Q'5 0.6'
arr
I tify that I have read this application and state that the PERMIT aEE r
above information is correct I agree to comply with all County IaeUANCE PEE —5—D 0`Q 9,-8`6
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 15Z _
upon the above-mentioned property for intpeetlon gurpwlu Y '
dQ[� SEE REVERSE FOR EXPLANATORY LANGUAGE
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Suture of P Date