HomeMy Public PortalAbout10528 KEY WEST ST_Miscellaneous__ WO:KERS'COMPENSATION DECLARATION 76M444
CE 875 (2-80) MIS,CELLA'NEOUS APPLICATION
I nOeby affirm that I have a-certificate of consent to self COUNTY OF LOS ANGELES" BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,-Lab.0)
Policy No Company FOR APPLICANT TO FILL IN BUILDING �//�
' - q,.. - ADDRESS s(J� 1
❑A Certified copy IS-hereby furnished BUILDING LOCALITY I
r ❑ - ADDRESS - n - .
Certified copy Is filed with the county building Inspection " NEAREST
LOCALITY r..-
• department , « t^ GRO SS SST' ,
Date Applicant NEAREST Y, y+ -DISTRICT NO/ G UP JTYPr PROCE BY
CROSS ST \ - '` /1 V CONSI� -
IdR•TIFICATE OF EXEMPTION FROM WORKERS' LEGAL } t i - rrr�U(7I l/
COMPENSATION INSURANCE DESCRIPTION LOT No '39 BLOCK MAP / //� HIGHWAY
' - ` NO, / /� (CIRCLE) STATE MAJOR SECO LOCAL
_ NO OF BL _ Q
(This section need,not be corripleted,if the work Involved TRACT a NOW F LOT USE ONE�SPECIALCONDITIONS
by the permit'is for one hundred dollars ($100) or less) _ V
USE TIN
SIZ fi.OF LOT �'' EXISTING jts
I certify that in the performance of the work for which this - O
permit Is Issued, I shall not employ any person in any manner OWNER " U
so as'-to become subject tosthe Workers' Compensation Laws MAIL OCCUPANCY GROUP' �� .W
- - ADDRESS
Date Applicant - U)
NOTICE TO APPLICANT If, after,making this Certificate of CITY NOL OCCUPANT LOAD z
Exemption, you should become, sublecti-to the Workers'
Compensation provisions-of the Labor Code,'you must forth- APPLICATION FOR EXIT HARDWARE
with comply" with such provisions or"this permit shall be TRAILER USE a c GEOLOGY INSPECTION❑ No Spec Knowl
deemed revoked, ° ❑ r
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION` " Panic DeVlces
I herebv affirm that I am licensed under provisions of Chapfer SAFETY'PERMIT Q ` (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my-Illcense Is in full force andNG.
effect ppRKISPACES REO'D,C� PROVIDED
License Number Lie Class r 017
LIMITED TIME USE
Contractor Date Q r DATE DATE
Q � IIFROM TO
I`am, exempt from the licensing requirements as I am a.' v
INSPECTOR'S
licensed'architect ,or a,registered professional engineer's SIZE OF' .�1/ NO OF
u acting in my professional capacrty`(Section,,7051, Bus- EXISTING BLDG��" STORIES SIG ATURE
inessand'ProfessiorisCode) FINIAL APPROVAL
PRESENT USE OF BUILDING
Lie or'Reg No Date
114
C
HOME OWNER-BUILDER DECLARATION No of D USEING BUILDINGS
ON LO AND USE
I hereby affirm that I am' exempt from-the Contractor's h" ;- - 7 6 3.7 A
License Law for the following reason'(Section 7031 5, Busi- _ '
ness and Professions Code) NO PARKING - #'• • 9',• 3 0
SPACES PROVIDED �� • •-�.�� 0
EJ 1,-as owner of the property, will do the work and the _i ` ,
structure,is, not',intended or offered for,sale (Section _ z
7044, Busmess and Professions Code) ;• • •,8 a5 Oct, -
r PROPOSED USE OF BUILDING �,-
CONSTRUCTION LENDING AGENCY r• v " " :�B,1� 8 7
I her'etiy affirm that there is a construction lending agency
for the performance of the work for which this permit Is r i
Issued(See,3097,Civ C)
Lender's Name PROPOSED MAx'occ ,o
Lender's Address^
PERMIT FEELU
_
L certify that I have,read this application and state that the
above information is-correct I agree to comply with-all County,^ ISSUANCE FEE ;
ordinances and State,; n
laws relating to building°costruction,' (
TOTAL FEE
and hereby authorize representatives of this County to enter
upon Waabboovve-mentioned o for inspection purposes SEE,REVERSE FOR EXPLANATORY LANGUAGE
10.1/271
Signature of reimittee r Dat