The URL can be used to link to this page

Home My Public Portal About10839 GRAND AVE_Miscellaneous__ WORKERS'COMPENSATIONDECLARATION CE MISCELLANEOUS APPLICATION CE 876 (1 1-B4) I hereby affirm that I love n certificate of conwht to ,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insure, or a�tiflcato of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN ■uILnING wDDRs/s -- Q Certf4ed copy in hereby furnished lU1LJJ</INGS LOCALITY AD DRS7 Certifled copy Is Bled with the county building Inspection LOCALITY L= N�wRseT department. CROSS ST. Data Applicant N<ARNSTDI�eJC 6 TYPK 'rR ■■ Y CROSS ■T. � ✓(�) CONST. CERTIk'IQATE OF EXEMPTION FROM WORKS Lt GAL COMPENSATION INSURANCE D<e CRIPT ION LOT No. pZ� BLOCK AlYHIOH.AY NO. (CIe CLA) ■TATs MAJOR ■SCOND LOCAL (eau. Section need not be eom Ieted If the Rork invo�ired TRACT /y NL Oi ON OT USK IONt I:C/PIAL CONDITIONS by the permit is for one hundred dollars ($100) or low) USK or, ■Izi or LOT Sx1/TING SILDG. I certify that In the pe¢formance of the work for which this permit Is Issued, I shall not employ any person in any mann gx OwNKR �' v so as to become subject to the Workers' Compensation Laws ' OCCUPANCY GROUP �o MA Date Applicant AD DR tSS F- NOTICE TO APP)_ICANT: If, after making this Certfficate of CITY ZUS ��70pz � ! 3 �� OCCUPANT LOAD CNJ Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILSR USK ❑ acoLOGY INSPULTION ❑ No Spec. Know[. deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY IN■PXCTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFLTY rtRYR ❑ LIST R1LYS ■S LOf) NO. OK XXIT■ 9 (commencing with Section 7000) of Division 3 of the Bnsi- mss and Prpfeudons Code,and my license is In fall force and effect 3 uyys C PARKING I ■rA CS/ Riq D � rROVID tD License Number Lie. Class z N //y//•. LIMITED TIME USE Contractor or Date `'1 DAT/ DAT/ ❑ I am exempt from the licensing requirements as I am a O d.5� P.... Tog licensed architect oI a regiEtered profbssional engineer SIZK OF No. OF IN/F<aTO R'/ doting In my professional capacity (Section 7051, Bus- S%I/TING BLDG.6. /T ORI<■ ■I6 NATURt Lwu and Professions Code). !'INAL APPROVAL 1 rR6/SNI USK OF BUILDING Lia or Reg.No. Date HOME OWNER-BUILDER DECLARATION No. OF XXISTING ■UIL.DING/ 1 ON LOT AND USK I hereby affirm that I am exempt from the Contractor's ACCT i License Law for the following reason (Section 70315, Buri- � g�. neo and Professions Code): NO. PARKING 00 I, as owner of the prop", will do the work and the /PACK■ PROVIDKD 1 ITQftS structure is not Intended or offered for sale (Section 7044,Business and Professions Code). I TOTAL. 93 . 00 CONSTRUCTION LENDING AGENCY PIlO PO16D USX OF BUILDING CASH ASH 93.0 I I hereby FiMrrn. that there is a construction lending agency IA 7 �1.I { HE for the performance the work for which this permit is .013Ied(Sea.3097,Civ.Q. Lender's Name (} { /[{ PROPOSID MAX. OCC. IJDOD-OM J/15 O Lender's Address � I certify that I have Ioad this application and state that the PQRMIT FCa '(190 7. 31 1 AM 945 above information Is correct I agree to comply with all County ISSUANCE Fsi 13, 00 ordinances and State laws relating to building construction, and he y authorize r roeentatNes of this County to enter TOTAL P[¢ upon bovo-men roperty r inspection purposes_ SEE REVERSE FOR EXPLANATORY LANGUAGE tore of Permittee Date �C"C/r1}� j�7�� /,�s�Z WORKERS'COMPENSATION DECLARATION 76M4" CE 876 (2-80) MISCEJLLr kNEOUS! APPLICATION I� reby affirm that I have / certlftcHte of consent to calf CO3. r F LOS ANGEL BUILDING AND SAFETY DIVISION or a certMcate oMorkers'Compensation Insurance,or C certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING Q r r 9AL ❑ ADDRESS Certified copy Is hereby furnished. ■UILDINa / We ADDRESS Certified copy Is flied with the county bullding inspectlon� department. LOCALITY 7"Y A I �Lr Date App Hcant NEAREST �/_'7 `J! DISTRICT NO. 6R Ur res rR0 ■/<D ■1 CROSS ST. ?�-� ;S--f G CpN/T CERTIFICATE OF EXEMPTIONTROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. ■LOCK NA NO. F BLDG/. r IOHwwY n0. 'a O�/ (CIRCLS) STATE MAJOR SECOND LOCAL (TIL ThL ( la section peed not be completed if the.wor$ lnvoh%ed' TRACT NOSOON LOT USE ZONt RECIAL C r+DITIONS O by the permit .is for one h dollen (5100) or las.) U usE of v I certifythat in the SIZE OF LOT EXISTING BLDG. y/ performance of the work for which th 0 permit is Issued,'I shall not employ any person in any manner oWNCR �•remit �{/L J3p /�1 to as to become sUbJect to the Worker' Compensation Laws. \ MAIL p�9 d ��y,r rLj p3� OCCUPANCY GROUP � ADpRES■ / Fete Applicant (fQ ) NOTICE TO APPLICANT: If, after ma$ G(n ing this Certificate Of CITY 1C wl{ 140. OCCUPANT LOAD z Exemption, you should become subject to the Workers' Compensation provisions,of the Labor Code, you must forth- APP KATION FOR EXIT HARDWARE: with comply with such provialons or this pa, it spall be TRAILER USE GEOLOGY INSPECTION I`t0 J Knows. ❑ deemed revoked. Pec• ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPmc-now Panic Devices I hereby ■ffh-m that I am licensed under provisions of Chapter SAFETY PERMIT L I (LIST ITEMS■QLOW) No of Ezrr� 9 (commencing with Section 7000) of Division 3 of the Bust near and Professions Code, and my license is in full force and effect. PARKING SPAC;S RKQ'D PROVIDED License Number Llc. Clara LIMITED TIME USE Contractor Data DAPI DATI I am exempt from the licensing requirements as I aa rRo`II roI m licensed architect or a registered professional engineer SIZE OF No. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus, EXISTING BLDG. STORIES SIGNATURE Ineas and-Professions Code). PRESENT USS OF BUILDING FINAL APPROVAL Llc.or Reg:No. Data HOME OWNER-BUILDER DECLARATION No. OF AXND UN0 BUILDINGS ON LOT AND IJ/E ;3021 A I hereby afram that, I am exenypt from the Contractor's License Law for the following reason (Section, 7031.5, Bull- # 010'./ 0 30 news and Professions Code); NO. PARKING SPA'C ES PROVIDED El1. as owner of the property, will do the work and the �,o e 8 Q 5,0 structure Is not Intended or offered for isle (Section D D DQ 5 7044, Business and Professions Code). PROPOSED USK OF 0161I.-DING CONSTRUCTION LENDING AGENCY 0.7- 217—8 4 I hereby affirm that there is a construction lending agency for the performance of the work for which this permJt is issued(Sec. 3097,Civ.C.). Lender's Names ' PROPOSED MA-X. OCC. Lender's Addrew LT6T MIT R¢E O I certify that I have read this Hpplication and state that the above information is correct.I agree to comply with pll County IANCH FEC (' ordlnanc�ea and State laws relating to building constructiotl, 1 AL FHSV - and h by authorize representatives of this County to enter upo a above-mentioned property for spectIon purpose. SEE REVERSE FOR EXPLANATORY LANGUAGE H Signature of Permittee Data 7/�y