HomeMy WebLinkAbout1239 AHTENA DR (2) R'ORKERS'COMPENSATfONDECLARATION 7sMaaa MISCELLANEOUSAPPLICATION �
� CE 675(11-841
1 heieby aff¢m that � have a cectiiicate o£consent to self COUNTY OF LOS ANGELES BUILDII�'G AND SAFETY DIVISION
insure,oz a certificate of Workers'Compensation Insurance,ox
a certifiod copy thereof(Sec.3800,Lab.CJ.
Policy No. Company POR APPLICANT TO FI LL IN OUILOING -��
AODPESS
�Certified copy is hereby furnished. eo��o�nc
anowess / LOCALITY �
�Certified copy is filed with the county building inspection LOCALiTV _�J —}�� HEAwEST
depaztment. u�[MM/�, caoss sr.
Date Applicant NEAREST r DIST![ICT NO, GROVP TYPE ROCESSEo 6Y
��o===r. G �D � 2 3 �o�=
CERTIFICATE OF EXEi1PTION FROM W'ORKERS' I,EOA4
COMPENSATION INSURAVCE oescn�nr�oN �or no. e�.ocK •'rn``�Z9��=a�E�
a (�b � 9TATE MAJOR 86CONp LOCAL
NO,OF BLOGS.
(This section need not be completed if the wock involved rancr ow oN�or use oHe SPEGIa�CONDiTIOrvs '
6y the pexmit is fo[ one hundxed dollacs (5100) ox less.) USE OF �'��
SIZE OF 40T fixI51'[NG eLOG. �
I cetti£y that in the pexfoxmance of the work for which this a o
pexmit is issued,I shall not employ any person in any mannei owneR Cf /�� G{f, Q,Q�Q �-'
so as to become subject to the Workeis'Compensation Laws. Mw�� � � OCCUPANCY GAOUP � o
wooness / U
Date - Appiicant �
NOTICE TO APPLICANT:If,aftec making this Certi£icate of nrr O' no�.�7�� �(�� OCCUPANT LOAO �
Exemption, You should become subject to the Workers APPLICATION FOR EXIT HARDWARE: -
Compensation provisions of the Laboz Code,you must forth-
Wltll comply Wlt�l $LLC�I PIOV1SlOI15 OI t}L1S �JCLlillt shall be TRAILER lISE� GEOIAGV INSPECTION p No Spec.Knowl. �
deemcd cevoked. �
LICENSED CONTRACTORS DECLARATION OCCUPANCV INSPECTION Panic Devices �
I hexeby affirm that I am licensedunde:piovisionsofChaptex 9AF6TY PERMIT� (LIST IT6M3 BELOW� � �
9(commencing with Section 7000)of Division 3 af the Busi- No.oR ewrs
ness and Pro£essions Code,and my license is in full focce and D p� �� � ^
effect. C PARKING REq'D � I PROVIDEp �
a /��� SPACE9 � ��
License Number Lic.Class K �
LIMITED TIME USE
Contractoz Date � o.re o.�e
�I am exempt fcom the licensing requuements as I am a .
licensed architect or a ecgistered piofcssional engineei s,z�oF No.or �nsa�zc+oR•s
acting in my professional capacity(Section�OSS�BUS- �%ISTWG BLOG. STORIES SIGNATVPE
iness and Professions Code).
FINAL APPROVAL �
Lic.oi Reg.No. Date PaEsenr use o�su��oirvc
/D� � �
HOME ORNER-BL'ILDER DECLARATIOV NO.OF E%lsTING aULL.O�NGs
oN LOT AND use
I heceby affum that 1 am exempt 8om the Contractoc's � -`-�9�a f�FS A
License Law foi the following xeason(Section 7031.5,Busi- � � g��j � � � ���
ness and PzofessionsCode): r�o,rwaxu+c
� I, as owner of the property,will do the work and the gPAC55 PROVIOE� ' , I • •p�.5� .
atrueture is not intanded oc offered foc sale (Saction . �� ' . � � • • •E'.G.5 r=
7044,Business and Professions Code). � ' .
COVSTRIICI'ION LENDING AGENCY PROPoseo usE oF eu��orne �" '� ° - � � � _��.�� ��' O Ez<`9--H'7 �.%��
t heieby afFum that there is a construction lending age�cy - � ,���"'� .�
for thc perfo:mancc of thc work for which this permit is
� issued(Sec.3097,Civ.C.),
Lender's Name
� PROPOSEG MAX.OGG. '
Lendex's Address �
I certi£y that I have cead this appLication and state that the PERMIT FEE b, OD
above infotmation is conect.I agree to comply with all County ISSUANCE FEE �, � �
oidinances and State laws te]aUng to building co�sisuction, �
and here6y authorize repiesentatives of this County to entex TOTAL FEE -
upo above-m t' n�d pr pe y£ ctFbn purposes.
I //�/ �/ _� �e (= SEE REVERSE FOR EXPLANATORY LANGUAGE
�l� ll�1Zf"'J
Signatur of Permittee Date � �
� irvsP�croF�s NorEs OWNE2-6UILUEI�UECL.AAATION
� I hei�eLy uftirm that(am esempt f�om tlte Contractor',s.
Liccnsc !:na tos thc followin^_rr:son/5'erriuir 70.iL5.
. . --- . Rusii��ss oir.[ Vrufrs��tnru� Cn<lrJ. �f�rr ri�r or ru�u�n�
� _ .. . , ' � _ __ � n� �°q nr�� ��ri.�i 1� tor s..rerc[, altr- m�> >rr,
'q- ! INSPFCTOFi'S
c� °_�b o.S oATC � . —. nt[r J-. � r pa.r n n �!t+-rao p i . fu ils i ii¢,� r,
SIGNATURE
— —. — '. ' - , . . It� �ni � r a�>T��rnt �r s�Jt Puivtt o i1 a
Tr.AI�_�r-l F , �. —' -- u .i�1 t t m nt tJra1 !r� tc 'ic .,��d ptu�si�m t t_ d�c
— — ----- —�--�--
r;TY pE�s��ilT — L����'�-�/�� �� 1 tc C?I[r�.tta f L t'rise l.aue �C/la�ter �7
. . <<nnurn r� � �tli S<c[�on iq001 .>f Dn��ieion 3 ui Ihe
TE�, �RARY � � . , . _ � . - .. . Rinir,r���c ard ('�vf<<si��r Cnl�°I or tka� k�. is etcn�T�7
5 FueTUR :'t'r=.o�:Eo � d�erci����rn n�id tl�c hasis I��r Nte a1�e�ged c.t�emptior�. �rm
� a���p,^.�v� — - — - . ..� . rioL�un�r of S-:�tio�i ?P.31 5 hr a�m appdirmi�jora pernrrt
TF l/(:TUFl. REMOVE� '
-- ue6is°cts tl�e cpF�ICemiE tu a eiril per�al�v of'not more tYia�2
.. Jirc h�wdred dnlGn'c(t S�p).
- � „ � ❑I,as owner of die property will do the wark,and
� �� ; "'" .,.'' ', .� '.'.,,.•_,�' � — the struclir:c is not in[ended or offezed foi s�le.
---- ------ ,, . .
Fiplr.LnPaPovAL � � ?S<<'. %0-1', (insuirss and Prq(e�ssta�s C'ode: The Cwo-
, . — — . — tr;acm��'s L�2�rir,'��i.a�r<loes not nPVh� to m�i om��er of
,. - pmperYr�cl�o lnitllr t-r intproret Utcrcori.¢red�rho dot�s�
� ,—'— .errelr ticnrk hir�tselJ p��orided ikat sierlr irriproren�er�l.e
� � � ��� ' arc iiot i��(er,dcd or n(/ered jor sa1r. IL howcrer. Utc
. — huildii(e nr r�rrpruvenxn! is snld �eifitin onr rem' of
� <•mnl�ltiion. ilir nu•rzcr-l���ilde� �ril! l�ore the hurdnn
qf P����'-'i��.��tA�.� he Jirl iwt I,ui1d a� inrprove J'or �Ire
. Purpu.ve�uf.ti¢!r./
I ani e�emp�wider S�c._ � ,
,, � � • � � ' � � I3&.P.C.for tliis reasoii
Date
Owner
~� , . INSPFCTOR'S NOTES ' � � - . -
�E�¢a_`�_..Vv� _ �rs
1,L14ww ws__�_ ,C.e�Qsm (a.
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