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WORKERS COMPENSATION DECLARATION 76M444 -
,,..�� CE 876(280) MISCELL' AN (� S APPLICATION
1 hereby^al(ftrm that I hese a certificate of consent to seer COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
myl�i or a certificate of Workers'Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C )
Policy No CompanjBUILDING ADOREsa �� rG
FOR APPLICANT TO FILL IN sJ
Certified copy Is hereby furnished BUILDING /
❑ .Dow¢SS LR Locwury
Certified copy Is filed with the county budding inspection
LOCALITY RARST
department E' CPOO/ ST
Date Applicant NEAREST Q b� DISTRICT NO GROUP Tvr¢ PSBR ee a¢O BY
Cg088 8T
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL b.v_
COMPENSATION INSURANCE D¢SCRIPTIon d9Y'1F6 3� Ioww.AT }
r ' A (c IAC L•) STATE ..IOR SECOND LOCAL a
/1 �/3 no oR cLDGS na e� U
(This aeChOn need AOI be hundred d if the work or Imd NDw ON Lor U¢H zone ¢PENAL conoln IONS by the plmmtt u for one hundred dollars ($I00) or less) �l
S12H OR LOT HxIuBE or
STING BLDG y cc
I certify that in the performance of the work for which this 0
permit is Issued 1 shall not employ any person in any manner Own¢w L .r/US!( (~j
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP _ LL)
IL paw el
Date Applicant
NOTICE TO APPLICANT If after making this Cernficate'of CITY 9 NoL 3 8. 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 W th such provisions Or this permit shall be TRAILER USE GEOLOGY INSPECTION
No P 6Q Knowl ❑
deemed res oked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
1 hereby affirm that 1 am hLensed under provisions of Chapter SwrgiY PERMIT ❑ (LIST ITEMS BEL.W) NO Or EXITS
9 (commencing with Section 7000) of Division 3 of the Bust _
ness and Professions Code and my license is in full force and Pw REIN.
effect RED o PRO.I.E.
arwc ca
License Number LIc Class LIMITED TIME USE
Contractor Date DATM DAT.
❑ AOM ro
1 em exempt from the licensing requirements as I em a � �
bcensed architect or a registered professional engineer alze oR '� J / D ��1 Per-d
acting In my professional capacity (Section 7051 Bus- Hx IST1 NO BLD. P aroglEe 1— 6r+w4
loess and Professions Code) PRESENT use or BUILDING FINAL APPROVAL
LIc or Reg No Date—
HOME
ate HOME OWNER BUILDER DECLARATION NO OP EXISnnG SUILDI
ON LOT wnD uac
1 hereby affirm that I am exempt from the Contractors 8 6 6 2 A
License Law for the following reason (Section 7031 5 Busi '
ness and Professions Code) No Pw R¢iNG • • • • 3 0
❑ BPA ccs PRovID¢o
1 as owner of the property will do the work and the
structure is not Intended or offered for sale (Section - 2 • • 8050
7044 Business and Professions Code) PROPOSED USE Or BUILDING / ,J • • • J
0 V O COU
,
CONSTRUCTION LENDING AGENCY l I U
I hereby affirm that there is a construction lending agency 1 2 2 9-82
for the performance of the work for which this permit is
issued(Sec 3097 CIv C)
Lender's Name
PRoroacD MAX occ
Lender s Address '
PERMIT FEE
1 certify that I have read this application and state that the ISSUANCE FEE O
above Information Is correct 1 agree to comply with all County �—
ordinances and State laws relating to building construction TOTAL FEE D O
and hereby authorize representatives of this County to enter �—
+pG t above mentioned pr�v arty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature f Permittee Date
,2J0s-,3I.f� 4 4-6 �T7 3 G