HomeMy Public PortalAbout9807 HALLWOOD DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 ' PPhICq ' IN
CE 875 (2-80) � 0S ��ELaANEOS h
I hereby affirm that I have a certificate of consent to self
insvl e, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec. 3800,Lab.C.)
BUILDING.
Policy No. Company FOR APP LI CANT TO FILL IN' ADDREss �Q _ fyZr7rZ/
❑ Certified copy is:hereby furnished. BUILDING' >>1 1 `�i LOCALITY '
ADDRESS '. Lr 7 ZZw E.. ..:_.
❑, Certified-copy is.filed with the county building inspection / s NEAREST
department. LocALlrr �/� �'G.M ,�y CROSS ST.
Date Applicant DISTRICT G TOPE i1PROCESSEDNEAREST TRICT NO. RO P BY
.CROSS ST. C✓�'r7/ IV V •'r'
CERTIFICATE OF EXEMPTION FROM WORKERS', LEGAL
DESCRIPTION LOT NO. .• BLOCK' --yy
COMPENSATION INSURANCE NOP C7((f (c Rc E) d
STATE M�AJO R'SECOND LOCAL '
(This section need•not be Com leted if the"work,involved : No. of BLDGs.
P TR AC T. /' T / NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one;hundred•,dollars ($100).or less.) _ L
.. vx. USE of
/ r�i�n,njii
- - SIZE OF'LO'1.7� _ I��� EXISTIN BLDG. . / � - � cr' .
I.certify that in_the performance cf the work for which this.
permit is issued, I shall not employ any person in any manner owNE'e F
/� :;$
so as to become subject fo the Workers' Compansation Laws MAILREG OCCUPANCY GROUP 0.
h � LU
ADDSS •�fl4' .. L�L��•L/GSL?� tL-
Date Applicant.. D` to
.NOTICE.TO.APPLICANT. If, after making.this,Certificate of c�rY � i°f_ TEL Y. 'No. (�,`��I OCCUPANT LOAD
Exemption, you. shoold become subject to the workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, y'ou.must forth-
, with Comply with, such- proyistons "or th1S•permit shall be TRAILER USE GEOLOGY INSPECTION No Spec. Knowl: ❑
deemed revoked ' � - Panic DeVICOS ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY InISPECTwIv
I hereby affirm that I am licensed under provisions of Chapter ❑i
Y F
SAFETY LIST Ireals.BE�ow) '.
- • ( NO. OF EXITS ❑ .
9 (commencing with.Section`7000)'of'Dlvisioq 3 of the Busi-
ness and P'rofessions'Cod&, and my license is in full force and
,effect - PUS_ �.:C.:7! PARKING 'REO'D PROVIDED
_ - - SPACES
License'Number Lic:.Class
LIMITED TIME,'USE'
Contractor Date DATE DATE
❑ ' FROM: ' TO: .
I am exempt from the,licensing requirements as-I am a.
licensed architect or a registered professional engineer' SIZE of NO. OF(^'� INSPECTOR'S.
acting ,in,my professional capacity (SeCtlOn 7051, BUS EXISTING BLDG., 45 STORIES r - SIGNATURE
inessand ProfessionsCode). �] FINAL APPROVAL
PRESENT USE;OF BUILDING �VMpvs Poem
Lic.or Reg.No: - Date �QxJJP1AAM-Ad1i'�
O EXISTING,BUIL;PINGS'
HOME.OWNER BUILDER DECLARATION
NO. F' ZJ
ON LOT AND'USE
I herebyaffirm that I am.„:'exempt from .ttie Contractor's / m/ ('i,( 1/I
License Law for the-following reason (Section.7031.5, Busi
ness,and Profession's Code No. PARKING �j
)'' SPACES PROVIDED - (�fit./P (J�(
❑,.I, as owner of the.•property; will do the work and the. / �'3 1 5 O A
structure is not Intended,or offered for sale (Section -'- l
7044„Business and Professions Code). {y o 0
PROPOSED USE OF,BUILDING
0 0 3 0'
CONSTRUCTION LENDING AGENCY : . 2'o yo'b 2.5'0,'
1 hereby, affirm that there is•a construction:lending agency
Lender's Name k for which this permit is o e'0 6
for-..the performance of the work =
issued(Sec:3097 Crv':,C). :; `,' ' . 3 ,.•S”.,�� 2.5 0
.PROPOSED MAX: OCC. 0 3..03, 8*2
,Lender's Address FEF2NI1 f FEE
I certify that I have read`this application and state that the
above information_is correct.I agree to comply ISSUANCE FEE with all County ' s ,
ordinances and State laws relating to building construction, TOTAL Fee
.and hereby aIuthoriz representatives of this County to, enter W e
upon the ve mfg ioned perty for inspecton- urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
3 �2--
Signature Permittee Date