HomeMy Public PortalAbout6106 SAINT JAMES DR_Miscellaneous_6/12/1986_ WPRKERS'COMPENSATION DECLARATION 76M4 (2 80) MISCELLANEOUS APPLICATIONCE {�
I dhere6y' affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �J
Insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C )
Policy No CoImpany FOR APPLICANT TO FILL IN BUILDING
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uowees ��� / , V�-T/17 ii;�r
❑ Certified copy is hereby furnished Bu1Lo1Na /� �r C
❑ Do R..S d S7; •Iof Loc wLlTv fC
Certified copy H filed with the county building inspection new REST
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department LOCALITY G� / CR08a ]T
Date Applicant neARSST G /�I oigw lir aRpyP Tvre / i•woc oar
aRaa9 aT K3 CON{V
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V
COMPENSATION INSURANCE 0SSCRnnon LOT no -LOC.
MAP aNww
O (clwc Le)
OF BLOGB STATE MAJOR BEC O LOCAL Q.
(This section need not be completed d the work involved TRACT MOWNO ON LOT USE ZONA SPECIAL CONDITION O
B U
by the permit is for one hundred dollars (S 100)
or IM) USK OF s
IoZE OF LOT E%ISTINO BLDG
I certify that in the performance of the work for which this own6Rll-
rC U
permit a Issued I shall not employ any person In any manner
so as to become subject to the Workers' Compensation laws \/`/lam /,/y� r` OCCUPANCY GROUP
MAIL /n/ (/ / • , / C/ a
ILI
ADD....
1/10 y
Date Applicant � -
NOTICE TO APPLICANT If after making this Certificate of Crry ��,( LF C( NOL P2�.�q/ /0f— OCCUPANT LOAD Z
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 USK GCOLOGY INSPECTION K
Spec nOWI ❑
deemed revoked 0 No ❑
LICENSED CONTRACTORS DECLARATIONi-�
OCCUPANCY INSPECTION Panic Devices
V
1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BHLOWI NO OF EXITS
9 (commencing with Section 7000)of Division 3 of the Bust
ness and Professions Code and my license Is In full force and -4C) /�0 PARKING
effect
SPACES RED O E= PwoViDHo
License Number Lie Class
LIMITED TIME USE
Contractor Date - OAT. DATE
0 1 am exempt from the licensing requirements ds I am a
I lcensed architect or a registered professional engineer size OPno OF INSPECTOR S
acting in my professional capacity (Section 7051 Bus aXian rve BLDG STORIES S NATuwe
mess and Professions Code) FINAL APPROVAL off
PRESENT USE OF BUILDING
Lie or Reg No Date
HOME OWNER BUILDER DECLARATION nn OF EXISTING BUILDINGS
o
N LOT AND u6
1 hereby affirm that 1 am exempt from the Contractors
License Law for the following reason (Section 7031 5 Bmi
ness and Professions Code) NO PARKING
BPA C ES PROVIDED
IDas owner of the property will do the work and the � -
structure Is not Intended or offered for sale (Section
7044 Business and Professions Code)
PRoeoaeD USE of BUILDING -
CONSTRUCTION LENDING AGENCY _ ;14 8 Q 4 A
1 hereby affirm that there is a construction lending agency # SSS B 3 0
for the performance of the work for which this permit Is
Issued (See 3097 Civ C )
Lender s Name PROPOSED MAX Dec 1 - - 8(150
Lender s Address PERMIT FEB 8 Q 5 0 5
I certify that 1 have read this application and state that the Q
above information B correct I agree to comply with all County issuwrvee FSE
ord ypes and State laws relating to budding construction TOTAL FEE s I�
here y authorize representatives of this County to enter d \S,Y,1✓rJ\y,-
Pon th ova. anti property for I eetlo purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 46�
Ig ature of Permitteel Date yl