HomeMy WebLinkAbout1210A __......., w,nrcNSATION DECLARATION � 76M444 �
CE675i2-80) MISCELLANEOUS APPLICATION
1 hereby afflrm �n�t 1 have n certificate oe consent to setf COUNTY OF LOS ANGELES BUILdING AND SAFETY DIVISION
' insure,or a certificate of�Vorkers'Compensation Insurance,or
a certi(ied copy thereo((Sec.3800,Lab.C.)
� Policy No. Compan3' woo�rsess �'���� ���.� �
FOR APPLICANTTO FILL IN '
� Certified copy is hereby furnished. ouuoiHo ;�, , , Ii ! LOCALITY /\
AODRE89 �'� .,.�..� L.JV 2 [��.�.t\ l •�v�:":..� %. 1
� � Certi(ied copy is filed with the county building inspection
NGAFGST
, depar[ment. �oewurv ;(V�.,...-�'- � '�r'J enoss sr.
,Date ApD���ant neweesr � � msrn�er r+o. enour rrre PROCESSEO er }
cRosssr. '+.�✓1,.� �:�;�.-�C cansr. a
CBR7IFICATE OF EXEh1YT10N FROAf WORKGRS' �Eca� , C
- COM1fPENSAT[ON INSURANCE �ESCRIPTION �or r�o. n�ocK �� V
(C� �E' STATE MIIJOR SECON�LOCAL �
(7his scetion need not he com teted if the work invotved ND.OF 9LOG5. SE ZON soceu�conmr�or+s J
P TR0.CT NOW ON LOT
by.thc permit i: for onc hundred dollazs(5100)or IessJ sc oF �
SIZE OF LOT E%ISTING 6LDG.
I certify Ihat in the perfosmance of lhe work for which this 1'
permit LS issued,I shall not employ any person tn any manner owrven �'1, � (.Y�� `_.,, 1!�(�;�;, �-�L,:i'L`•.,�.� -' Q
so as to become subject to the N'orkers'Compensatfon Laws. Mp�� -1 � OCCUPANCY GRDUP �
ADGRE55 1:.,�/ I �<' , � O
Pate Applicant � a.
TE{..- y'� I
� NOTICE TO ANPLICANT:IC,affer making Ihis CertiCicate nt errv 1%i;;�1({ •�+.�! ��;��NO. �(t���frf - (j,..��� OCCUPANT LOAD �
Ezemption, you shou�d become subjeci to the Worke�s' APPLICATION FOR EXIT HARDWARE: F"
Compensatiot�provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shall be aai�en uss GEOLOGV INSPECTION
- deemed revoked, � ❑ No Spec.Knowl.
LICENSGD CONYRACTORS DECLARA7IDN occwwacr�Hsrccnor+� Panic Devices ❑
1 hereby affirm that 1 am licensed under provisions of Chapter swFerr veam�r q (usr�rems ee�ow� NO.OF EXITS �
� 9(commencing rvith Section 7000)of Division 3 of the Busi- ' �
ness and Protrssions Code,and my license is in full forre nnd ��"4„t`�� �';' I<.! �I �.,r i :�-' eKmw
eFfect. sPwees REO�� �� PFOv1OE0 �
License Number Lic.C1ass '�� i��� � ��,
;�� LIMITED TIME USE
Cantractor Date � x•�1' ` owre nwre
� I am exempt from the licensing requirements as I am u
licensed architect or a registered professionai engineer sae pc No.oF �NSPECTOR�S
acting in my professional capaciry(Sec[ion 7D51,Bus- Ezisrwe BLOG. STORIES sewnruwe
iness and Yrofessions Code), rqcscnr vsc or oui�me+e FINAL APPROVAL
Lic.or Reg.No. Date
� }IOAtH DIVNLR•BUILDER DECLARATION ND.OF E%ISTING 9UILOINGS
on�or wrvo use
� 1 hereby nffirm that�1 am exemp[ from the Contractor's
License Law for the loilowing rcason (Section 7O3�.S.BO51- NO.PARKING
ness and Yrofcssions Code): ,. ,
SPACES PROVIOED �
� 1,95 ow�e� or rnr property,wiil do me wark and the ,-�..1.�E G h
stmcture is not intenJed or oflered for sale (Section � �•���. .�
7044,pusiness and Professions Code), pRoroseo use oF au��oinc �4'•'�",'�'`�t�
� CONSTRUCTIDN LGN➢ING AGLNCY ,t1,�,rl��C.,•r.]G
�, I hereby aFfirm that thete is a constroction lending agency � �
for the performance o(the work for tvh��h this permit is !,.�,.,��t�H Q t-
' issued(Sec.3094,Civ.CJ. � � +
Lendefs Name PROPOSEO MP%.OCC. {�"t�•���������
Lender's Address PERMIT FEE 7 ' �
t certiry that I have read this nPp���ation and state Ihut[he �SSUANCE FEE /
above information is corrcct.I agree to comply with all County /'' ' '
ordinances and State luws fBldllllg f0 bI1111IiOg COtl5If11CIlOf1. TOTAL FEE �,(.� �
and hercby authorize represen[atives ot this County m enfer .
uDa��he abore�mentioned pro erfy for inspection purposes. SLE REVERSE FOR GXNLANATORY LANGUAGE � �
�r� '✓'(,j::`i . . .-J� i,�
Signature ot Fermiltee Date �'