HomeMy Public PortalAbout5548 ROBINHOOD AVE_Miscellaneous__ WORKERS'COMPENSATlnN'DECLARACrorr CE
MISCELLANEOUS APPLICATION
I CE 876 (2T�0)
I horn, op 0 cors that I rave a certificate or comet.to self. COUNTY Off' LOS ANGELES BUILDING AND SAFE'L'Y�DIVI,SION
lrlsuro, or � certifLcate of Workers'Cb>rlpena�tlon Iniunncetor
L certified copy thereof(Sec.3800,Lab,C,)
.Po 11c NO.�-•Coltlpeny� - - �UILDIMG ,
FOR APPLICANTTO 6LL IN ADDR[s■ i
aCert[fled copyls hel-sby furritahed. cul- No pry r
ADDR[a■ �• _ a fn Qa .� LOCALITY -
Certified copy Is flledvAth file county buLldlpg inspectio[( N[AR[■r
. -department. LOCALITY CROSS ■T.
Date N[AR[1T L r P TISICT N 6 U -irY� a: rrl
' CRO.■ •T. d we
CBRTIFICATE OVEXEMPTiON¢RO4 WORK.P_R$' LKGAL .+:
COMPENSAT�bN tNSURANCIa DucRarT18H Lor no, ■4gLK. rNio' „GIRC-<Y, STAT[ MA�JOII SECID LOCAL'
CThli.Mc'tioh neer not be CM 1� if the VMrk 1]M o. or ■LDa,. r ( )
pp i��{ilVed TRACT NOW ON I OT• W Zd [ ar[C1 NIJITIONi
by too �tlt it for Due hundred do11*m 0100) or IML) `-'
u�st of ..
Aire or Lar [x18TINa BLDG. lis
I' certify that in the performhnce•of`the work for which•thisp O.
permh,is issued, I shall not employ any person in Any manner. 0-NR-R �� � �d �p AC/
so as to become subject to the.lYorkm'Compns
eatton L&Ws. Mw c r OCCUPANCY GF106P-
AD�Ru; �D f m 60
Dste, Applicant LL; ti TWL. Z
NQTICE'TO-APPLICA-NT: If, after m■kng-thU Certificate of, CI.Ty j Na. ud�.�. 37 3• bCCUPANT LOAD
Exemption, you should become subject tq the. Workers'
Compensation pfovislcns of the Labor Code, you mug,forth- APPLI ATION FOR EXIT HAFIDW�4R :
with comply with such provisions.or this permit shall be -tRA1IL[R Usi[� GEOLOGY In.rsICTION� Nd Sp@C. KIIOWI. a
deemed i•evol5ed. �8f11C �OYIC@S
LICENSED COriTRACTORS DECLARATION OCCUPA%CY Uf4T[CT
I heroby Affirm tl aj Ism licentel under provislom or Choter
9 (commeg_ctng with Se ctlon.7006) of DIYWon'3,of the Buai,y tAF[rY rsieMlr q .(LIST Irsus ■eLmr) NO. OWAEXITa
moss and.Profesdom Code, anal my lhrenae is In Yell force.and...
. RAC[■ PROVIDa:D
License Number_ Lic.'Claw r / �--1
-L1MUEf TIME- U$E
<CQntfeCtor -DstE owTt. .
I atn exempt from the llcbrutnk req�iromenrs as I am a
licensed architect or ■ ioes erod' professional•enkinegr •Last Or No. or INR[troR'■
acting In my profeasloh&l.cspacfty (Section 705L BUS- =XI.TING ■LDa. ■TORRs, AI ATUR[
meas snd'Profmclone Code). FIN
rRR5[NTUJ91Z Or BUILDING ' AL APPRQVAL
Lia or R64.No. Dite_ _
HOMEOWNER-BUILDER DECLARATION No. or sxlatlNG ■uiLDINa'.
ON LOT AND UR[ / y
• •,• 1
I hereby affirm.that I am bkompt ffom. the ContractgrY
Lttense Lavy for the followln� re4son (Sdctloh 7031.5, Ouxw' .�..'.. 8.0 Jr t4 .
nese and Prol`assi0 da NO. PARKIN¢¢
I, as' owner of the,property, will do the work and the .7
8QSfl9`.
structure is not 'tntanded or offered for sale (Sectton ,
7044,Busttlon and Profession Code). O ,� a4 8` ]
rROPQA[D USE OT ■UII.DING- , - .
CONSTRUCTION LENDING AGENCY, -
I hereby••affirm that there is a construction lending agegCy S
for the performance of.the'work for,vichich -this p"It is r
inued (Sec. 3097,Civ.C,). I '
Lander's-Name--
rrtoroA[U'itAA..00C.
Leader's Addreas_ TERM IT PEEC
I bertify that I hpve read tt}is eppllcatioq And state that the
Above information is corrdct.I agree to comply with Till County. �sstiwnca P4 E,
ordinkncak and State laws'reratjng to-building coustrugdQn, To rw� r[[
end here authodXe representetives of this.County to enter
U *bove-men ned property tor hispection purposes. 5EE REVERSE FOR EXPLANATORY LANpIl'�G -
ro of ee Dote ��� ��: .. `• .• - . . . .. ,