HomeMy Public PortalAbout5635 PAL MAL AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 7GM444 .. '
CE 975(11 aa) MISCELLANEOUS APPLICATION {�
1 hereby affirm that L have certificate of consent to sell
IpsCOUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION LJ
ure, or a certificate ofCompensationrs'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company BUILDING
FOR APPLICANT TO FILL IN AD OR Ess
�❑ Certified copy Is hereby furmshed BU ILDINa LOCALITY
ADORC56
❑ Certified copy is filed with the county budding inspection
department ' LOCA LIrY O - NE wq ear
CRO.. ST
Date Applicant cnoss sT 2 ( DlazgycT O url ry P¢ Z rR es By
'l' J corvsr
CERTIFICATE OF EXEMPTION FROM WORKERS' ST
r
COMPENSATION INSURANCE DE.cRonoN Lor rvo > BLOCK , ���p cis a� STATE MAJOR s 'COND LOCAL
(This section need not be completed if the work Involved TRACT S - NOW 0. �o as 5t Q anl� ZONE SPECIAL CONDITIONS
Iby the permit is for one hundred dollars ($100) or less) USE ory�
6%I a
SIZE of Lor
cl'Certify that in the performance of the work for which this eQL o
permit is issued, I shall not employ any person in any manner OWNER PAOA,4 V In a Sul A 11 - v
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP o
S U
Date AppApplicantADORES.can[ w
L
NOTICE TO APPLICANT If, after making this Certificate of clrr ` NO6� b OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- I APPL ATION FOR EXIT HARDWARE
,with comply with such provisions or this permit shall be ❑
deemed revoked TRAILER use ❑ GEOLOGY INaP¢crloN ❑ NO Spec KnOWI
LICENSED CONTRACTORS DECLARATION OCCUPANCY IN.recTlo Panic Devices
1 hereby affirm that I am heensed under provisions of Chapter SAFETY PERMIT ❑ (uar ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busr ND Or EXITS
ness and Professions Code, and my license is in full force and �
effect I d ` \I• PA gKINa Pq OVIDED
`
License Number Lic Class +/y�" ! ^ \ srwcEe qE0 DLIMITED TIME USE
Contractor Date ' ` �rb�lyJ� - - ..T. DATE
I am exempt from the licensing requirements as I am a Ifir ICN %I L, TO
licensed architect or a registered professional engineer C oP No or IN9PC CTOR S
acting in my professional capacity (Section 7051 Bus ex IND BLD. , "TORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL
Lic or Reg No Date
PRESENT USE or BUILDING
HOMEOWNER-BUILDER DECLARATION No OF EXISTING BUILDINGS 3/13f .Cl!
ON LOT AND USE VOID
I hereby affirm that 1 am \exempt from the Contractor s -
License Law for the following reason (Section 7031 5, Bust,
ness and Professions Code) No PARKING 5,iQ7 t'1
I, as owner of the property, will do the work and the SPACES PROVIDED 1
structure is not intended or offered for sale (Section a
7044,Business and Professions Code) ACCT.T
CONSTRUCTION LENDING AGENCY PROP099D USE OF BUILDING `3137 93.C10
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) CC-1 p r' n �i �i
�0I� - dp
Lender's Name u
PROPO.FED OC
Lender's Address CHECK 73•10
rC
H
I certify that I have read this application ca
PERMIT FEE 92on and state that the VL
above information is correct 1 agree to comply with all County ISSUANCE FEE �I O .-. ,
ordinances and State laws relating to build-, construction, L'.
and hereby authorize representatives of this County to enter TOTAL FEE ,V G� QQQ[I-O[IQ1 77 j�q(1
upon the above-mentioned property Or inspection purposes
SEE REVERSE FOR EXPLANATORY L�j,E`GNGE .O
�s ` a +�— w w I.C.. 1546 1 AN 113:10
Sig lure o Pe ittee Date v G ,�_, G ,