HomeMy Public PortalAbout10159 LYNROSE ST_Miscellaneous__ �w 't4ORKERS'COMPENSATIONDECLARATION CE 875(2-80) WSvELLAKEOUS APPLICATION
I hereby affirm that I have a certificate of consent to Self I
COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a%ertificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab'C.) ` " , .
'Policy No CompanyBUILDING
FOR APPLICANT TO FILL IN ADDRESS /✓
0(Certified copy is hereby furnished BUILDING �� LOCALITY
ADDRESS .�' L.yNQ,J
❑ Certified copy Is filed with the county buildmg'inspectlon q NEAREST
department LOCALITY ���'AA D�y� CA� , CROSS ST'
Date = Applicant NEAREST DISTRICT G OU TYPE / PRO ED,BY
CROSS ST a 5D CONST /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL VVV
COMPENSATION INSURANCE DESCRIPTION . LOT NO- BLOCK MAP•6/�THIGHWAY
NO. F BLOCS
r+o C`� '�73(CIRCLE) STATE MAJOR SEC D LOCAL a,
O 0
(This •section need not be completed if,the work-involved TRACT NOW ON LOTUW
OU
NE SP ECIAL'CONDITIONS
by the permit is for one hundred dollars ($.100) or less.) USE of _O
SIZE OF LOT �� EXISTING BLDG - 0
I certify that in the performance of the work for which this 0
permit is issued, i shall not employ any person in ariy manner owNErx ( M '� C- D U
so as to become subject to'the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ' FZ
,5 w
• - - ADDRESS
Date Applicant, ?�
NOTICE TO APPLICANT' If,:after making this Certificate of CITY T NOL �'^Z✓D6 OCCUPANT LOAD
Exemption, you should become' subject to the Workers' APPLICATION FOR EXIT HARDWARE
`Compensatioriprovisions of the,Labor Code, you must forth-
,wlth comply with such provisions or- this permit shall be TRAILER USEGEOLOGY INSPECTION
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
Panic'Devlces El
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
ushness and Professions Code, and my license is In full force and ill (.r�x PARKING., r-�
effect - - SPACES REO'D I I PROVIDED
License Number Lie Class ��JJ
�l(,l1n LIMITED TIME USE
Contractor Date _v 5 DATE DATE
FROM TO
I am exempt from the licensing,requirements as I am a
' r -
licensed architect'•or a*registered professional'engineer SIZE OF NO. OF r INSPECTOR'S
acting in my professional capacity (Section.705 1, Bus- EXISTING BLDG. STORIES / NATURE
mess and Professions CodIe) PRESENT USE:USFINAL APPROVAL
„ E OF BUILDING ,
Lic or Reg No Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's rl e o 8 Q 50
License Law for the following reason (Section 703,1 5, Bust- o e'o $05,05
ness and Professions Code) NO PARKING
SPACES PROVIDED
® 1, as owner of'the property, will do the work and the 0 3,0 6,t 8 7
structure is not-.intended or offered for-sale (Section ,
7044, Business and Professions Code). `
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work'for which this permit is-
issued(Sec 3097,Civ C)
Lender's Name PROPOSED MAX' OCC
Lender's Address_ 1
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 hereby authorize representatives of this County to enter
upon Ithe above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pe Date