HomeMy WebLinkAbout0862A (4) \VORKE2S'COSIPENSATfOUDECLARATIOY 76Maaa M ISCELLANEOUS APPLICATION �
CE 875(17•64)
t hereby affirm that 1 have a ccrtificate of conscnt to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insuie,or a certific�te of�4'orkers'Compensation Insurance,or
a certified copy theieof(Sec.3800,Lab.CJ. �
PolicyNo. Company FORAPPLICANTTOFILLIN e❑uou+c �SS
AOORE55 `
�Ceet�ed capy is hereby furnished, eu��o��c �S� ' fnl ee� Mas�e � '
1100RE55 LOCIIL�TY � f�n_
�Cert�ed copy is Ciled wi[h the county building inspection v�\
department. �oenurr`�;���`�1� �v�. �i 1 Lf�`]1 S� NEARLST
�J �..h'� -� {lL GRO55 ST.
Date Applicant NEAREST o�srrsicr no. owouv rr E PROCES e e•
�Ro===r. �,a;�, �Tt�k , �o�=�N
CER7IFICATE OF EXEIIPTIOV FRO\t R`ORFERS' �eca4
CO\1PENSAT70V INSI]RA[�CE ' � oescairrior� LOT NO. �� BLOCK Nwv ���q�i' STATE MAJOR SECONO LOCAL
A��(�� NO.OF BLDGS. I
(This section need no[be compleled if the work involved TRACT � � NOW ON LOT � USE ZONE SIEGI0.L GONDITIONS
by the permit is for one hundred dollars(5100) or IessJ use or
S�ZE OF LOT ���' ���� EXISTING OLOG. �
1 certify that in the performance uf the�ti•ork foe�ahich this � o
permit is issued,1 shall no[empLoy any person in any manner ow�eR ���pt s, �yrA1���Zw�r'� � `�
so as to become subject to the�1'orkers'Compensation Laws. Mp�� t OCCUPANCY GROUP o
Date Applicant ADDRESS ;��,� fk;iU�� Lht. �
NOTICE TO APPLICANT:If,after makinF this Cert�cate of cirr�{p.;,ti�,�� � No� ( ���-��� DCCUPANT LOAD z
Exemption, you should become sttbject to the �Yorkers' qppLICATION FOR EXIT HARDWARE:
Compens�tion provisions of the Labor Code,you must forth- ' �
�vith comply n4th such piovisions or this permit sUall be {RA�LER�se❑ ce sPecnoN❑ Na SpeC.Knowl. �
deemed revoked. �
LICENSEDCONTRACTORSDECLARATION occurwNcv�H,Peonor+ �PanicDevices �
I liereby affizm tlut I am LicensedunderpcovisionsofChapter snFerr PERMIT❑ (L19T ITEMS 6ELOW) - � �
9(commencir�with Section 7000)of Division 3 of the BusF NO.OF EXITS
ness and Professions Code,and my license is in Cull force and n_ �
� effect. �n� ���f l'.. �TQA�t �ul�u+ PARKING pEa•o � PROVIOEO �
SPACES
License Numbei Lia Class �•� LIMITED TIME USE
Contractor Date � o..� o.r�
� 1 am exempt Crom the licensing requirements as I am a �
Gcensed architect or a registered professional engineei sae ov No.oF INSPECTOR�S
acting in m}' piofessional cap�city($ection 7051,IIus- Ex�srir+e o�oe. y��� S STOPIES ,2 SIGNNTVRE
iness and Professions Code). � 1(�
Lic.or Reg.No. Date PR�SENT VSE OR BUILOING � �� FINAL APPROVAL �/��Q,P �/F b11
UU �Cl�
HO\lE 01VNGR-6UILDER DECLARATION No.or ex�sr�xc eui�o�Ncs
ON LOT ANO USE
I hereby affirm that I am exempt from the Contractor's .
� LIcense Law for the following reason(Section 7031.5,Busi- �
ness and Pmfessions Code): Ho,rARK�Ne �
� 1,as owner of the property,will do tLe work and the SPACES PROV�OEp
structure is not inteaded or offered for sale (Section .
7044,Dusiness and Professions Code).
COVSTRUCIIO\LEKDII�G AGENCY PROPOSED USE OF eui�oiNc �, `O��2 p
I hereby affirtn that there is a construction lending agency
for the perfozmance of the work foi which this petmit is #` • ' °��
issued(Sec.3097,Civ.C.).
Lender's�amc I • •S G 5 0
PROPOSED MAX.OCC.
Lender's Address • • �E Q 5 Q�
1 certify that I have read this application and state that the �ERMIT FEE � O
above information is wrrec[.I agree to comply with all County iss�nNce FEe l G�� 2^$8 �
ocdinances and State Imvs rela[ing to building consuuction,
and hereby authorize zepresentatives of Q�is Counry to enter TOTAL FEE $
up ie above- ent[oned operty for inspection purposcs.
I t�� SLE REVERSE FOR EXPLANATORY LANGUAGE • .
, 'L � ' ����i . .
Signature f Permittee Date ' . �I
_ .. . , ws�ecTOR�s r�ores 05�'NLR-I3U(LbGR ULCLARATIOV
. .. . , � . f hereby;iflirm tl:a[1 am ezemp[fram tLe Conv:iciur's
. . � . . . . . . - ..... - . . . . - �� - � Liccnca L:nr for thz follo�cine rc;ison lSre7io�t i0�1.?.
.._ ._. __ . . . -. . - __-.. . . __ _ .-_ Husinrss and�Pn�(ecei<ms ('ndi•Jr .1nr ri(r nr�riumn'
� � '� ' �� . . iJu.k i q mc c.perntt7 to ro�,s:+'uc:. alfci..tn rurr
� A�'Pi70�AL� � ....�'DATE - �ttJSPCCTOfi'S . . . .. ._ 'J __' . ' [1 r�i l.�l. r r � •rrt• �lnictr�rc�.1'r«�� frr�Ic r.s �i�r��
sicr�nrune ;,i.1 ' �;iL' I '
r_i.,,-��, clsu nq.urr.� d.<�ct/dirn� f r� su�'L prnn�l �u Jilc n
TRt.1LER USE � - - � � s:'itid s1a(rrnuit dicl L< is licen� f �i.si�m:( 1�� ih�•
. . '��� 1�' �':1 �:�::;� l.. � � 1'ro��.u�int of 71ii• Curb�2ctn✓s !.r<unc 1�m�IClwytri-J
SAFETV PEFMIT,�. � �. -- � � (�orrin����ttir�c «t'!r .Scclrn�i 7()0�� of U<<+ti��i� 3 ri(.!!te .
7eh1PORARX . . . � �� � � '���' Busur�sr nml Proicsvo��s Cn,Jr1 u� dtn� hr i� i�errrpt
STRUCTURE APPFOVED ... '. . , lli��r<�li���»i r.��t<(Ilr��l�n5ic l�r�i•Ih��t(Irgr:(�:rr�rt/�fir�rt. .-1���' ,
TEMPOFAFiY ' . � , . _ �'irl�ttirii���(.Sirt(rirt i(Ij1.5)�t'Cril'C/�F+li(ttit!JrJra pfr!ltif
STRUCTURFflFMOVEn
. , � . . xuLjrc75(lic nnry'icunf fn a cirif penm'll'qf nul urorr 7han
- . - - -- - -. _� - - � fire luvidred dn(!c��s(5 i0(/).� - . , � .
� . � .�.� , ��� . . .. . O i,as nwncr b(thc pmpc:[p�vill do thc��ark,and
� - - �-- � - � Uu structuic is not intcnctcd oi offrrcd Co[sal�•. ` ' - �
. , ���,� �-,� � , . , ,� ��" ' � � /Sr�. i044. fl�rr�nesr artd R�afi�ssiuns Cudc: 7�hi' Cui�-
FINAI APPROVAL � . '. . fracl�r's l.ic��rrs�� f.r.��• ch�<�s nnt nJ+j�li' 1<� a�i <>itn��r nJ
_ � � i.�
- - - . . _ � propc�rfp iohu f�uilds or imprnres 77�crcort,nnd ulio doe�
, . . � � ,. ' ' � -,.:.� ' sudt-�rnrk l�i+vr�lf prurpl<•d Nrt:t sucli i+apmicmcqls-
...._ _ . � , ��-•� �.� ,� . . , . . � ,.��. .
- - - � - - -_ . ._ -. - � --� - � cre iint irtfrndrd ur nj7arrd Jnr salc. IJ. l�oirercr, d�t
. , - . .. - l�uildi�r� or nn;�rnrcu�cnf h� anld t��itdirr onc rrm�n
...I . c'nnr/�Ir:iai, dre o�.��ncr.hurldrr.x�il( l:m�r nc� burdan
' �-. . o(pruri�l: Umt hr di�l nnf biiifd nr irnprori°-J'or!pe
. __ � - . . , . p�vp�iu•of,tial<�.f . .
- --- ' 1 am cxcntpt iindcr Sec. .
. _ _. _ . . . , .., . �,'l.t;�� • . . . . . .
� ' [3 C P.C.for tliis rcason
�_r _ ., _.
__ _ ,
� ,
Date
O���ncr
INSPECTOR'S NOTES ' . - - . _ . _ � � � � � . ' �
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