HomeMy Public PortalAbout10052 LYNROSE ST_Miscellaneous__ j WN4KERS'COMPENSATION DECLARATION E 875 (1.1-84)
CE MISCELLANEOUS APPLICATION
:` ,'-• .,. ' C 875 - +
"I hereby-affuAm that 4 have.a. certificate'.oft.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 F1 LL IN BUILDING
.. A;DDRESS /.t.L9 2 .
F'�,Certified copy,ls hereby furnished. BUILDING j �j/- LOCALITY (�
ADDRESS •� ��- ,Q
`0 Certified copy`is•filed with the county building inspection LOCALIT, —' NEAREST
department:
,�1 CROSS ST. `
/� .L�. G -
DateApplicant. NEAREST DISTRICT NO. CygOUP TYPE RO SSED BY
. CROSS ST. CONSST7 .. I
CERTIFICATE OF EXEMPTION FROM WORKERS? LEGAL �-
a�4
COMPENSATION INSURANCE DEscRI`Priori Lor No. BLOCK MAP��o y'rlwnv o O
- NO.// �- (CIRCLE)
STATE MAJR SECOND L CAL-
1110. OF BLDGS._
'.(This.section need,'not-be Completed"-lf the'work Involved TRACT NOW ON LOT / U ONESPECIAL CONDITIONS -
Py the permit is for one hundred dollars,($100) or less.) . use of
SIZE."OF;LOT `J9 EXISTING BLDG.
I certify-that-in the performance of the work•forwhich this ,
permit is issued'I shall not employ any person,in any manner, 0WNEe U yC y
so as to become Wbjecf:.to the Workers''Compensation Laws. MAIL D nn OCCUPANCY GROUP [` �o
Date'` Applicant AopREss �� L ��'• F
TEL. ,�/���/ ,W
NOTICE TO APPLICANT: If, after making this Certificate of CITY - M�Z� . NO. -14� 2'3036 OCCUPANT LOAD N
Exemption" you should become subject to the Workers' z
Compensation provisions of the Labor Code,.you must forth- APPLICATION FOR EXIT°HARDWARE:
with com ly'with' such rovisions or this ermit shall be
II _ P I> TRAILER USE ❑ GEOLOGY_INSPECTION ❑ NO Spec. KnOWI.
deemed revoked:•
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9.(commencing with Section'7000)of Division 3.of the Busi- NO. OF EXITS
ness and.Professions Code;and my license is in full force and -
effect. �- PARKING REq'D D PROVIDED
SPACES -
License Number Lia Class
3l2 S. 1 l�1 LIMITED TIME -USE
Contractor Date DATE DATE .
_ .
a � - 'I am exempt from the licensing requirements as I am a N l oLIDE ^LCI -4 3 O"1 . , FROM: TO:
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
de). - FINAL APPROVAL
PRESENT USE SOF BUILDING
Lie.or Rega doProfessions Co ;Date
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-
ness and Professions'Code): No. PARKING
SPACES PROVIDED
I,'as owner of the property; will do:the work and the _ 604,6A
- structure is not' intended'or•offered'for sale (Section
7044,Business and Professions Code). 0 3,0
R
PROPOSED USE OF BUILDING -
CONSTRUCTION LENDING AGENCY, l o o $Q 5 0
A liereby-,affirm that there_.is.,a-construction-:lending-agency.
for the performance of the :work for which this permit is ° ° ° 8 5 0 c=I ±
issued(Sec. 3097,Civ.C.).
.. Lender's Name
1-2:0 2,='8 6
- PROPOSED.MAX. OCC. ,
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
„ ordinarices,,and State laws relating to building-construction,
and hereby authorize representatives of this County to enter - TOTAL'FEE. �..
` up.Qn the above-- en lo ed', operty for inspection purposes. `
^. \ F SEE.REVERSE FOR EXPLANATORY LANGUAGE
Signatureof. ermrttee "Date. _ ,