HomeMy Public PortalAbout10673 ROSEGLEN ST_Miscellaneous__ WOR It3'r7rRS'COMPENSATION DECLARATION 78M4"
w4-K ; .., CE 878 (2-80) MISCELLANEOUS APPLICATION
I hereby atiert that L have ■ certificate of consent nc ■alt COUNTY OF LOS ANGELES BUILDING AND SAF'E'TY DIVISION
Insure, or ■ certificate of Workers'Compensation Insurance,or
■certlned copy thereof(Sec. 3800,Lab.C.)
I
Policy No. Company FOR APPLICANT TO FILL IN ■wuoIOINa
'L
❑ Certified copy is hereby L
by furnished. ■uILDINOCALITY
ElADDR[Sl
Certified copy Is tiled with the county building inspection M[AR[eT
department. LocwLIrYB�'�''` �(� /ot��s—�2c��A CROs/ ■T.
DatO Applicant N[ARE/T r DISTRICT N 6 OUr TY rE WSKCD
CRO// ■T. L �` CON
CERTIFICATE OF EXEMPTION FROM WORKERS'
LEGAL AL
COMPENSATION INSURANCI� DESCRIPTION LOT No. ■LOCK 'Ar ///��/A, /7�/ r Ior wwr }
No. /U/V "IGH(CIR .i) STAT[ MAAL 11
//--br�i�g� NO. Or ■LDa■. ^
li"" aeCtiOII II00d IIOY l)o completed 1[ the R'OIY involved TRACT �+ NOW ON LOT US[ ZO K SPECIAL CONDITIONS `}J{
b7t the permit 1s for one hundred doUm ($100) or low.)' USK Or
SIZE Or LOT EXISTING ■LDa.
I certify that In the performance of the work for which this Q
permit Is Issued, I shall not employ any person In any manner ovnER ��
to as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP W
Date Applicant [n
ADDRESS/4673 C 05
NOTICE TO ATEL.
PPLICANT: If, after mtkipg this Certificate of CITY s No. OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER OSE GEOLOGY INSPECTION NO Spec. KnoWl. ❑
deemed revoked. Panic Devices E]LICENSED CONTRACTORS DECLARATION
OCCUPANCY
❑
I hereby affirm that I em licensed under provisions of Chapter SAFETY PERMrr Lt (LIST ITEMS ■GLOW) No. or [xlr■
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my License Is in full force and PARKIN,.
effect. or ACES RKQ'D I�-� rROVID[D
License Number Lic.Clara
LIMITED TIME USE
Contractor Data DAT■ DAT■
❑ I ■m exempt from the licensing requirements as I am • r ROY T01
licensed archttect or ■ registered professional engineer SIZE or NO
Or INSPECTOR'/
acting In my professional capacity (Section 7051, Bus- EXI/TING ■LDa. STORIR/ 71GNATtkRK
InessandProfessions Code). FINAL APPROVAL
PRESENT USE OF BUILDING (�
Lic.or Reg.No. Data
HOME OWNER-BUILDER DECLARATION No. [XI/nna BUILDINGS
ON LOT AND U/E
I hereby affirm that, I am exempt from the Contractor's I
License Law for the following reason (Secilon 7031.5, Busl- �2 3 Q 3 A
neva and Professions Code): NO. PARKING
SPACES PROVIDED
I, as owner of the property, will do the work and the
/ 3
structure is not intended or offered for sale (Section # /
7044, Business and Professions Code). ?,� .� • a Q 5 0
PRoro/[D u/E or ■u1LDlna
CONSTRUCTION LENDING AGENCY I
c a u 8 Q 5 Q r 1 ,
I hereby affirm that there Is a construction lending agency �L 2
for the pdrformance of the work for vd ilch this permit Is c &21
2 1 i 8 5
issued (Sec. 3097,Civ.C.).
Lender's Names PROPOSED MAX. OCC.
Lender's Address PERMIT FEE
I certify that I have read this application and state that the IsseuAHCE FEE
above Information IS correct.I agree to comply with all County
'ordinances and State laws relating to building construction,
and hereby authorise repr nt■tives of this County to enter TOTAL FEE
u n the above- n property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Data