HomeMy Public PortalAbout9828 KEY WEST ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 8
CE
(2-80) MISCELLANEOUS APPLICATION
CE 875
I hereby 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 C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished BUILDIN }��jl / LOCALITY f e-
ADDRESS U 4`[� N• fi+'� "'..
Certified copy Is filed with the county building inspection r NEAREST CROSS sr
department LOCALITY t pl nJ14
bate Applicant NEAREST �I r- DISTRlJ-T NO GROUP TYPE r PRO SED BY
PP CR SS sr = i / / --� s/'LN=J2 d , i✓rf �!" CONST�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL. / RL }
COMPENSATION INSURANCE DESCRIPTION LOT O BLOCK PE (� RcEY
rj ( I STATE MAJOR SECOND LOCAL d
O
e cometee work TRACT NOW ON LOTT NO
`(This section need not bld.if the involved NO OF 6L USE ZONE SPECIAL CONDITIONS U
i
by the permit is for one hundred dollars ($100) or less.) � �J USE OF �7 f LU
• 'SIZE OF LOT-.57S.� f'�/ '4 EXISTING BLDG ( i J
I certify that in the performance of the work for which this , f LL
permit is issued, I shall not employ any person in any manner f OWNERy (y61 I J
so as to become subject to the Workers' Compensation Laws iii! R
MAIL K� OCCUPANCY GOUP 1
• ADDRESS Q
Date Applicant 1
TELA_, t OCCUPANT LOAD 0
NOTICE TO APPLICANT If, after making this Certificate of 'CITY�I �/�i NO ,1' �� EL
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth- 2
with comply with such provisions or this permit shall be TRAILER USE E] GEOLOGY INSPECTION - No Spec Knowl ❑ a—
deemed revoked ❑
OCCUPANCY INSPECTION Panic Devices
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed•under provisions of Chapter SAFETY PERMIT i (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is m full force and t�1J rG� _ PARKING.
effect / REq'D O PROVIDED
PAC
SES II��JJ
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 (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE
iness and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL
Lic or Reg No Date
ti
HOME OWNER-BUILDER DECLARATION NO'OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Busi-
ING-
ness and Professions Code SP PARK
) SPACES PROVIDED ,
EJ 1, as owner of the property, will do the work and'the
structure is not intended or offered for sale (Section
I ,
7044, Business and Professions Code) PROPOSED USE OF BUILDING 1
�,♦ O'�O 11 ��
CONSTRUCTION LENDING AGENCY r
I hereby affirm that there is a construction lending agency ( ;.F3 , ,
for the performance of the work for which this permit is
i issued (Sec 3097,Civ C) a,l� °, 0
i Lender's Name PROPOSED MAX OCC tl j i
Lender's Address PERMIT FEE
I 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 laws relating to building construction, TOTAL FEE
and hereb thorize representatives of this County to enter tr 1
Ye ab�o/v�-menti ned�property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pe mittee Date