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Home My Public Portal About9721 VAL ST_Miscellaneous__ WORKERS COMPENSATION DECLARATION 78M444 CE 878(280) MISCELLANEOUS APPLICATION 1 hereby affirm that I have a certificate of cement to self COUNTY OF LOS ANGELES ' BUILDING AND SAFETY DIVISION Insure or a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C ) Policy No Company FOR APPLICANT TO FILL IN BUILOIG ADDRUS 2 i ❑ Certified copy Is hereby furnished Du 1LDINa q A LOCALITY /_ C ❑ wooweer Certified copy u bled with the county budding inspection NEw RweT department LOuury (r �/L' �.Is f ego99 IIT � C �— Dale Applicant NEARESTDISTRICT No GROUP rYP¢~v Pwoe SEDsr Cg099 9T /�� Corry CLRTII ICATL OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRiPT1 oN LOT No BLOCK r �/ `> IG.W.Y Y AlP (�l�L> �; I...CLRI STATE MAJOR SECOND LOCAL a Thu section need not Ise completed d the work Involved NO OP SL T USE zone SPECIAL CONDITIONS 0 ( P TRACT NOW ON LOT (� by the perms[ Is for one hundred dollars (5180) or less) use oP SIZE OF LOT EXISTING YLDa 1 certify that in thL performance of the work for which this 0 permit Is Issued I shall not employ any person in any manner OWNERs so as to become subject to the Workers Compensation Laws MAIL � OCCUPANCY GROUP K_� W wODR... a Dale Applicant Z TE NOTICE TO APPLICANT If after making this Certificate of CITY NoL y S�744 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 USE GCOLOGY INSPECTION❑ NO$ EC Knows ❑ deemed revoked P El CONTRACTORS DECLARATION OCCUPANCY I"PECTION Panic Devices 09 1 hereby affirm that 1 am laensed under provisions of ChapterSAFE Tr PERMIT q suer ITEMS NO or exITS a 9 (commencing with Section 7000)of Division 3 of the Bust _ nets and Professions Code and in) license Is In full force and effect PARK." SPACES REG D D PROVIDED License Number Lie Class LIMITED TIME USE Contractor DatL D.T. OATS ❑ To I am exempt from the licensing requirements as I am n I censed architect or a registered professional engmeLr SIZE OF NG or INSPECTOR 9 acting in my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES SIGNATURE mess and Professions Code) PRESENT USE oP BUILDING FINAL APPROVAL Lie or Reg No Date HOMEOWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS oN LOT AND USE 1 hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Bust ness and Professions Code) NO PARKING8 1 2 4 A EJ1 SS owner of the property will the work end SPACES PROVIDED the # R R S • 3 0 structure Is not intended or offered for sole (Section 7044 Business and Professions Code) PROPOSED USE OF BUILDING ` 2•' S 62 50 CONSTRUCTION LENDING AGENCY SSS 62505 hereby affirm that there is a construction lending agency for the performance of the work for witch this permit Is _ 12 0 7•_$2 Issued (Sec 3097 CivC) Lender's Name PROPOSED MAX OCC Lender s Address PERMIT PCE I certify that 1 have read this application and state that thL j above Information Is correct I agree to comply with all County ISSUANCE FEE d ordinances and State laws relating to budding construction TOTAL FEE and hereby authorize representatives of this County to enter upon the bm. mentio d pro rty for Inspection purposes S E REVERSE FOR EXPLANATORY LANGUAGE er �L• [�$ Signature o ermrttee Date �11.611 �(l WOkKERS �ODIPENSATIONDECLARATION CE 875(11 841 M ISCELLANEOU§ APPLICATION {1 CE 876 LJ I hereby affirm that I have a s'Co of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure!or a certdimd te of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN SUILDINEo `� ADDRSS Certified copy is hereby furnished EUILa ING o7� M E// LOCALITYawlqa Certdied copy Is filed with the county budding inspection LOcw LITY T' NEAREST department CROS/ ST Dale Applicant NEAR./T DISTRICT," "7TYPE Pwo u[D EY CROSS .Tconn CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DS ScwvT1ON LOT No / BLOCK woP jelweL.j STAT[ MAJOR BE NO LocwL TL G l —�� of SLOG/ ^� (Thu section need not be Completed If the work Involved TRACT IO /�^�—'— KOw ON LOY sy. u/ ZONE V[cuL CONDITIONS by the permit Is for one hundred dollars (5100) or less) .r3G J /SG tie[ o/TIN. ° [L a I certify that in the performance of the cork for wroth this SIZE Or LOT /� [l{I e permit is issued, I shall not employ any person in any manner OWNER L so as to become subject to the Workers' Compensation Laws MAIL r-p_ Da , OCCUPANCY GROUP �'1 0 r r AD DR[.. C: l =J Date /s sXApphmnt / w NOTICE TO APPLICANT If, after making this Certificate of CITY j� ,..� 9 it NOL 7 5G-9d 109 OCCUPANT LOAD Exemption, you should become subject to the Workers APPLICATION FOR EXIT HARDWARE Compensation provisions of the labor Code, you must forth with comply with such provisions or this permit shall be deemed revoked TRAILER USE OEO OV INSPECTION ❑ Pa Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION PemC Devices I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busy NO PERMIT (UST ITEMS BELOW) No or [Xrct nese and Professions Code,and my license is in full force and effect PARKINS RED I� PROVIDED License Number Lic Class SPACESLIMITEDTIME USE Contractor Date DATA DAT/ I am exempt from the licensutg requirements as I am o TD licensed architect or a registered professional engineer SIZE or . NO Or INv[crow a acting in my professional capacity (Section 7051, Bus- EXISTING BLOC 3�. L4 X y.3 •TORI[. r RE men and Professions Code) �,/ FINAL APPROVAL Lic or Reg No Date Pw u[NT BLS[ or BUILDING �I HOME OWNER BUILDER DECLARATION No Or EXISTING BUILDING/ • • • 8 Q 5 D ON LOT AND U.[ 0729-88 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING 1 as owner of the proy, will do the work and the /PACES PROVIDED VPuc[ure is not intended or offered for sale (Section 7044,Business and Professions Code) R 0 3 1 rROPO/6D U/[Or BUILDING CONSTRUCTION LENDING AGENCY a • •tt I hereby affirm that there is a construction lending agency \.�\(vL_S for the performance of the work for which this permit u I " issued(Sec 3097,Cw C) Lender's Name • • 5 D 5 Lender's Address PROPOSED MAX Dec 0729-88 1 certify that I have read this application and state that the ^[KNIT wee a above information is correct I agree to comply with all County ISSUANCE PEE ordinances and State laws relating to build-, construction, and hereby authorize representatives of this County to enter TOTAL FEe upon the above-me tnoned property for inspection purposes SEE REVERSE fOR EXPLANATORY LANGUAGE �i Signature of Permittee Date