HomeMy Public PortalAbout9831 VAL ST_Miscellaneous__ RS COMPENSATION DECLARATION 76M444 �-I
1 . CE 875111841 MISCELLANEOUS APPLICATION �ILfl1
1 evert by atttrm that 1 have a certificate of consent 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 BUILDINGk3l ` L Is
T
AD ORQ98 C-� J
Certified copy Is hereby furnished DUILCIADOREeeNG tS LOCALITY
Certified copy u Pifed with the county budding inspection Loc wLlrr NEAREST
department cn09e ar
Date Applicant NEAREST DmrRlc a Tr PE PROCQ89[D Dr
CROSS ar CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE G[a eR IPT 1o. Lor NO sc.Oex 1O1"^' STAT[ MAJOR 9e eon LOCAL
NO OF BLDOS Z N
j<IRc R)
(This section need not be completed If the work involved TRACT 6 NO,
ON LOT UaONE SPECIAL CONDITIONS
by the permit Is for one hundred dollars ($I00) or less) uaQ oP
SIZE OF LorQ aw[TINa BLDG
1 certify that in the performance of the work for which this o
permit Is Issued, I shall not employ array person in any manner oBNEeIIJ
so as to become subject to the Workers Compensation Laws NAIL OCCUPANCY GROUP ` .3 0
Date ApplicantM
NOTICE TO APPLICANT If, after making this Certificate of CITY NOL OCCUPANT LOAD
Exemption, you should become subject to the workers' qpp CATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be rwwILER USK ❑ GEOLOGY INSPECTION ❑ No Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY maPe Brow Panic Devices
1 hereby affirm that 1 am licensed under provisions of Chapter
awPQrr PERMIT ❑ (lar Ir[we BELOW)9 (commencing with Section 7000) of Division 3 of the Bust
mNO OF EXITS
ness and Professions Code,and my license Is in full force and
effect Famdw Room aindPARKIN a REG0 D PROVIDED
aPwc[e
License Number LIc Class
LIMITED TIME USE
Contractol Date I ' ' DwT[ TO OATK
D1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer slaE OF
TING
OP INSPECTOR S
acting in my professional capacity (Section 7051, Bus- KX's BLDG STORIES 9 Nwru[Q
mess and Professions Code)
PRESENT use OF BUILDING FINAL APPROVAL
LIc or Reg No Date
HOME OWNER-BUILDER DECLARATION No Or EXISTING BUILDINGS
ON LOT AND USE
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 \
0 1, as owner of the property, will do the work and the SPACES PROVIDED
structure Is not intended or offered for sale (Section
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING �• :\", m`�. f $9�Q,Q 3 A
1 hereby affirm that there 1s a construction lending agency �_`3 0
for the rformance of the work for which this �� - �
Issued(Sec permit Is 3097,Cry C) p J I a • 8 Q 5 0
Lender's Name [ S a 8 Q 5 0 cr3
PROPOSED MAX OCC
Lender's Address PERMIT PfiH o4, 18-88
1 certify that I have read this application and state that the
above Information Is correct I agree to comply with all County ISSUANCE FEE ,J
ordmances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL PEC
up the above- Honed prope for spectnon purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Vbisf e of Per Date