HomeMy Public PortalAbout10831 GRAND AVE_Miscellaneous__ Y
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ON
I ha byO` W.a that IThave a�xxrttflx$Ce of consent to .elf CE 876(„-84) M I SC E L LA N EO U S ig,P P L I C A T I O N
I hJ
insure or a certt$Lato of Workers'Compeniation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DMSION
a_rt�8ed copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN ■UIL�INo / /?
- AD DRQ/■ GC�
FlCertifled copy is hereby furnished. ]BUILDING f C) u
ADDR]E/■ LOCALITY
ElCertified copy IS filed with the county buIlding impaction LOCALITY N]EARXST
department. e CROSS WT. _
Date Applicant X<AR■fT r _` p DISTRICT XQQQ. aaOUP JTYPX C]E1S]ED ■Y
CROSS ST. /• y �L ��� (J` CO No's./
CERTIFICATE OF EXEMPTION FROM WORKERS' L:6AL ;1
COMPENSATION INSURANCE D]E1CRIPT ION LOT NO. HIGHWAY
wo. (CRCLII 1TAT]E YAJOR 1]ECOXD LOCAL
y XO. OF ■LOGS.
(j]lfj bCtiQII IIBEd not be CQnplO tDd it tll0 WOTk iIIVOIrOd Tl[ACT XOi ON LOT USS: ZONIS frt QIAL CONDITION■
by a permit is for one hundred.dollars ($100) or less) USX Or
SIZ[ OF LOT ]EXISTING ]BLDG.
I certify that in the performance of the work for which this ) � C�
permit is issued, I shall not employ any person in any maffier OWN]ER S>
ao as to become subject to the Workerd Compensation Laws MAIL I�Qr OCCUPANCY GROUP o
Date A licaat AD D R]E of �-� 241 t
NOTICE TO APPLICANT: If, after making this Certl$cate of CrrY NO� $j$ O/-,may OCCUPANT LOAD °
Exemption, you should become subject to the Workerr F V
Compensation provisions of the Labor Code,you must forth- APPLIC TION FOR EXIT HARDWARE:
with comply with such provisions or this permit {hall be TRAIL]ER USK ❑ GKOLOGY INSP]ECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY IX■PXCTION ❑ Panic Devices
I hereby affirm that I am Licensed under provisions of Chapter
9 (commencing with Section 7000) of Divisfon 3 of the Buss ■AF]ETY P]ERYrr ❑ (LIST R]EY■ ■]ELOi) F
NO. OF ]EXITS
peas and PTofeadons Code,and my license is in full force and
�� FA RKIXa R]EO'D rROVID]Ed
License Number Lia Class
LIMITED TIME USE
Contractor Date - DAT/ _ DATR
PwDrI
I am exempt from the lid requitements as I am a TDI
licensed architect or a registered profbaional engineer far OF f No. OF In■P]EaroR /
acting in my profesdonal capacity (Section 7051, But .'rim. ■LD.. STORI]E■ ■IG TUR]E
iness and Professions Code). G� FINAL APPROVAL
Lia or Reg.No. Date PR]Ef]EnT u■]E of ]Bu1LDInG
HOME OWNER-BUILDER DECLARATION MO.of ]ExlrrlNo ■UILDIXa■ Ll�
ON LOT AND USX
I hereby affirm that t am exempt from the Contractor'sK. T•T
License Law for the following reason (Section 7031.5, Buss- - � 1Eti•c��
nests d Professions Code): NO. PARKING
1, as owner of the property, wM do the work and the ■Pecs■ PROVID]ED
party 1 ITEMSFstructure is not intended or offered for sale (Suction �I LTi - r�
704.4,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSXD USK OF ]BUILDING CHECK i i 1■�`
I hereby affirm that there Is a construction lending agency lrcl.l�,
for the performance of the work for which this permit is
iuued(Sea 3097,Ctv.C.).
Lender's Name _j}j} fI J i /
PROPOSKD MAX. OCC. CI 3 -IIL 1 1L,/ 10/91
Lender's Address v 1
I em-tfty that I have read this application and mate that the PERMIT FKIK 1224.dLel442 1 AM10-*20
/above information is correct I agree to comply with all County Iaau ANC]E Ff]E
ordinances and State laws relating to building_construction,
and hereby autho representatives of this County to eater TOTAL FKK 5c�
up the a zIa tionod roperty for inspection purposes
X:: rO j SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of P8rmtttee Date