HomeMy Public PortalAbout10112 LYNROSE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76 44 (2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have 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
E] Certified copy is hereby furnishedBUILDING
ADDRESS '
LOCALITY
0 Certified copy Is filed with the county.building inspection NEAREST
department LOCALITY '1 CROSS ST
Date Applicant NEAREST DISTRICT NQQQ G OUP TYPE P ESSED BY
s - CROSS ST. 1L ,D'�/ CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a (�
DESCRIPTION LOT NO. BLOCK
COMPENSATION INSURANCE MAP ( )
NO. OF_BLDGS }
NO CIRRCCLELE,s STATE MAJOR SECOND LOCAL LL
(THIS SOCtIOn need not be completed if the work Involved TRACT - NOW ON LOT USE ZONE SPECIAL CONDITIONS O'
by the permit is for one hundred dollars ($100) or less.) U
USE OF
• SIZE OF LOT EXISTING BLDG - CC
I-certify that in the'performance of the work for which this
permit is Issued, I shall not employ any person In any manner OWNER 0-
'so as to become subject to the Workers' Compensation Laws OCCUPANCY GROUP U
MAIL - UJADDRESS c
Date Applicant O� `�� � U)
NOTICE TO APPLICANT If, after making this Certificate of CITY^ NO OCCUPANT LOAD z
Exemption, you,should become subject •to the'Workers' APPLICATION FOR EXIT HARDWARE
Compensation provisions•of the Labor Code, you must forth-
with.comply with such provisions or this permit shall be TRAILERUSE GEOLOGY INSPECTION
❑ ❑ No Spec. Knowl.
deemed revoked
P
OCCUANCY INSPECTION Panic Devices
LICENSED CONTRACTORS DECLARATION ❑ - '
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 in full force andOF Roo F ��tz V+ pp ING.
'effect
`�• ' SPA ES REq'D I 1 PROVIDED
License Number Lic Class T LIMITED TIME USE. u
Contractor Date GATE DATE
I am exempt from the licensing requirements as 1 am a.
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
mess and Professions Code)• FINAL APPROVAL 91//�
PRESENT USE OF BUILDING >�i j{�
Lic or Reg .No. Date (f 6r
HOME OWNER-BUILDER DECLARATION + NO OF EXISTING BUILDINGS,
ON LOT AND USE -
All-r-Ir SL
I ,hereby affirm that I am. exempt from; the Contractor's
License Law for the following reason (Section 7031 5, Busi-
nessand Professions Code) NO PARKING ;
SPACE S PROVIDED
ElI, as owner of the property, will do the work and the 1
structure is not intended or,offered for sale (Section s�:; (y� 93 m 00
7044, Business and Professions Code) _
PROPOSED USE OF BUILDING _ Ht('�'-('• �i jljl
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency _f-EAINGE --
for the performance of the work for which this permit Is i
issued (Sec 3097,Civ C)
Lender's Name PROPOSED MAX occ - 1 l�4"lEilti� 4, 3/-`�
Lender's Address PERMIT FEE /4 _ �y~� � z {'t
1 certify that I have read this application and state that the I [/ \ •
above rmation is c r ct.I agree to comply with all County ISSUANCE FEE
ordl nce and Stat ws relating to'building construction, TOTAL FEE
and ere aut on presentahves of this County to enter-•.
U
nth abov property for in, a tion urposes SEE REVERSE FOR EXPLANATORY LANGUAGE-
Si rPe Date