HomeMy Public PortalAbout5405 SANTA ANITA AVE_Miscellaneous__ WORKERS'COWENSATION,DECLARATION 78M444 ;, MISCELLANEOUS APPLICATION
i h�b}I.� that I pave a certificate of c6nscnt to self COUNTY OF LOS ANGELES BUILDING AND'SAFETY DIVISION
luau of Lficate of Workers'Compedsation Insurance, or
a certified copy thereof (Sec 3800; Lab. C) -
Policy No. Company FOR APPLICANT TO FLL IN SUILDO+G
r� BUI I Amwrae.
u�ll Ctrtified-copy is hereby furnished
tertified copy'is filed with the coup building NEARE T
county g inspection ZIP �D
department I' NFARear
crrosa e-r.
Date Applicant SIZ1 OF L F b ON DInTR1GgpuF Tvre ED
/LL/ coNit
CERTIFICATE
��OF EXEMPTION FROM WORKERS' A. �«K LOTN6.
CO+•4�EN.SATIdN INSUR_AN rp .. . �cztculp STATE MAJOR oECOND LOCA11—. .'• ,
(This section need not be completed Lf the'work Involved A"E940R MAP BOOK PAQE� usa ZONLI SPE GOND e
by the permlt is for one hundred dollars ($100) or less.)
I certify that, in the performapce of the.work for which thiself-
L (' _Q7.pertpit is issued, I shall not employ any person in any manner J
90 as to become subject td the Workers Compensation Laws. AD �•
OCCUPANCY GROUP
Date_Applicant YtP
NOTICE TQ APPLICANT: If, after making this Certificate 7e,_ J OCCUPANT LOAD 1
of Exemptioh; 'you -should become subject to the Workers' APPUCATION FOR EXIT HARDWARE:
Compensation,provisions of,the Labor Cade,you must forthwith
comply with such'provisions'or this' permit .shall be deemed TRAILS usz❑ -
revolted iaoiocr IN Pec'TION❑ NO Spec Know. El
Occuw,NCY 1NSrScTIOP1I- Panic Devices ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Licensed under provisions of Chapter _ _ &AFL-rY FSR❑ tLLsT mrms saw t
9(commenting with Section 7000)of Divisiop 3 of the Business NO.OF mare
and Professions Code,and my license is in fhltforce'arid effect
PARKING• REWD DDED
License Number Lie. Class > 70
Contractor Date LIMITED TIME USE1 I� .
- - _ ❑
F-1I am comp[ from the m .,.NOTAL
licensing require
FROM: DATE 242
requirements as I am a '
Licensed architect or a registered professional engineer
acting in m professional capacity (Section 7051, Business SIZE OF No.OF INSP8cT0
242.70
and Professions Code). �I'TI'�°LDO bTOOF-
61GN AT
Lie- or Reg: No. Date �Esff-Nr usF of euabiNa - - FINAL APPROVAL `
HOME OWNER-BUILDER DECLARATION NO. EXImNG Isun�I L' 1 /6/ 3/96
ON LOT AND USE Of i24 1 AM10.3b
I hereby affirm that I am exempt from the Contractor's License I O!i
Law for the following reason..(Section 7031.5, Business and
PID ODS Code): NO.PARKING
IJLes owner of the property, will do the work and the SPACES Pit"D SD
-
structure Ls pot intended or offered for sale(Section 7044, FROPOAED uSE OF BUILDING
Busipess and Professions Code).
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 P>zo 4 MAX. �
Sea
( 3097, Civ. Q. - -
der'ss Name
Lender's Address ,D
I certify that I have read this application and state that the
above information is correct l agree to comply with all County PERMrrE
ordinances and State laws relating to building construction,and O� T
hereby authorize representatives of this County to enter upon
l the ab e-mwtionsp
ed r r inection purpose Iesuwr+cE . O `
TOTAL PEE • n
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ofPe ittee Date -