HomeMy Public PortalAbout10038 GREEN ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 876 (1��4)4
CE M ISCELL 'NEOUS APPLICATION
87
I herpt*T.ldiniethat I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
huuro os a certiflcate of Workers'Compensation Insurance,or
a a+rt�fled copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRK/■ 'Y7
Certified copy is hereby furnished. But-D1NG00 7 Ott S `– —C-A111ADDRK/■
F department is Bled with the county building inspection LOCALITY j `� �� NKARK.T
CROSS ST.
NKARKST i DISTRICT NO. G Out TYrK K//KD BY
Date Applicant CROSR ■T. �+` 3 ConrT.
CERTIFICATE OF EXEMPTION FROM WORKERS' LKGAL
COMPENSATION INSURANCE DKSCRIrTION LOT NO. BLOCK r p HIGHWAY
Ho. (olwo i) /TATK MAJOR SB GOND LOCAL
L
(+"'sNO. OF BLDG■.
Section need not be COIIlpleted if the work involved TRACT NOW ON LOT USK ZONK /PKa CONDITION■
by the permit is for one hundred dollars ($100) or lees.) USK or
■IIK Or LOT K ISTING BLDG.
I certffy that in the performance of the work for which this cD
permit is issued,I &hall not employ any person in any moaner orNKR
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP
ADDRKSI o 14 54Ce
Applicant TKL.
NOTICE TO APPLICANT If, after making this Certificate of arty No. 5 7 3 ? S OCCUPANT LOAD
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shaIl beL] ❑ No Spec. Knowl.
deemed revoked. TR AILKR UDK 6KOL0 GY IN■rK CTION
Panic Devices
LICENSED CONTRACTORS DECLARATION ocaurwncY INarKaTlon��
I hereby affirm that I am llcenjpd under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Bgsi KwrKT, rKRMIT ❑ (LIST rrKYs BKLo><)
no, or Kx1T■
nese and Professions Code, and my license Is in full force and c
effect. ■rA cKs G W '�N O O rA RKQ D rROVID KD
CKS
License Number Luc. Class cc o O l E
LIMITED TIME USE
Contractor DatOr
W Noe r DAT. DATK
El �_� G,L I} rworl
I am exempt from the licensing requirements as I am a Cul � C Tol
licensed architect oI a registered profbssional engineer SIZK Or n0. r INSPKRK
acting in my professional capacity (Section 7051, Bus- KXISTING BLDG. ■TORIKS SIGMAuR
inm and Profetsions Code).
rR KSKNT USK OF BUILDING FINAL APPROVAL ���
Lia or Reg.No. Date
HOME OWNER-BUILDER DECLARATION No. or KXISTING BUILDINGS / //��
ON LOT AND USK ANT.
I hereby affirm that I am exempt from the Contractor's 33133 234.45
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No. rARKING 1 IiEM
I, as owner of theroperty, will do the work and the •PACK, PROVIDKD
structure Is not intended or offered for sale (Section TOTAL 234 etc
7044,Business and Professions Code). CWX 234.45
CONSTRUCTION LENDING AGENCY rROrOSKD USK Or BUILDING CU44GE
I-C
I hereby affirm that there Is a construction lending agency
for the performance of the work for which this perm-tt Is
issued(Sea 3097,Civ.C.). M_Ow1 i L/129/94
Lender's Name
PROPOSKD MAX. OCC. 7915 '1 I 71
FI5:
Lender's Address 1 11
P[RMIT FEE
I certify that I have read this application and state that the
above information is correct I agree to comply with all County ISSUANCK FK[
ordinances and State laws relating to builconstruction,
and hereby a orhe representative of this County to enter TOTAL FEE a�
upon the a mentio property f inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitt Data