HomeMy WebLinkAbout0633A �R'ORKERS'CObIPEVSATIONDECLARATION 76M444 MISCELLANEOUSAPPLICATION
CE 875(11-84) �
1 liexeby affum that 1 have a cexti£icate oi consent to seu COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISIQiN
insure,or a cextificate of\Vorkers'Compensation Insuxance,or
a cettified copy thexoof(Seo.3800,Lab,C.). 7 7 r
PolicyVo. Company--�— FORAPPLICANTTOFILLIN pOp6E5S /�,75 G/E'���� v�
�Cextified copy is hereby furnishcd, u��o'�� �33 � ��� �� �a��rv /��gK� ��� ��, f�G�
AD�RESS
�Certified copy is filed�viYh the county building inspecYion �ocwurv /� ne�s� `/
depaxtment. . �!l'f, pYJ /I 7�� J`- S T�^ �S�
Date.— —Applicant — *+EeREsr. �!'�1���� T isTe,qr�o. RouP rPer wocsssEo ev
�a� � G �s
CERTIPICATE OF RXEMPTION FROM WORKERS' �tiecw� F] f
COMPL.NSATIOV INSURANCE COESCRIPTION ��T N .�✓✓ HLOCK aP ljj+�i� {c� �s) STATE MAJOR SECO �LOCAL
(This section need not be completed if the Hrork involved ranc� �'�JrS NOW ON LOT g I �S6 ZOrvE sPec�nt coNo�nons
by the pexmit is Poz one hundxeQ dollazs ($]00) or lessJ use oF
gIZ6 OF LOT EXISTING 6LOG. �
I certffy that in the perfozmance uf the woik for which.this o
peimit is issued,I shall not employ any pesson in anY mannex owxER�y�o� ¢ �ag���C . � �
so as to become suhject to the R'orkexs'Compensation Laws. `� OCCUPANCY GROUP �
bate Applicant wonRess �j j �rP��fyjgpt�� t/I<= �
rei. 6L
NOTICE TO APPLICANT:If,aftex making this Certificate of c�rv p�� /L mo. � �..,�3 f� OCCUPANT LOA� N
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Coda,you must forth- APPUCATION FOR EXIT HARDWARE:
with comp�v with such provisions ar this permit shall be rRA���R�g�� G60LOGY WSPECTION❑ No Spec.KnowL �
deemed revoked.
LICENSF.D CONTRACTORS DECLARATION CCOPAN°'''"'�PE`T'o"'❑ Panic Devices �
I hereby affum tktat I am licensed undex pzovisionsof Chaptei snra�r PrRm�r� (Lisr�rems ee�ow) �
� 9(commenciqg with Section 7000)of Division 3 of the Busi- �.,/ No.oF ex�ra
ness and Professions Code,and my license is in full force and. .� ,f artoLn �/— PARKING
effect. ��-'�L R6qD � rwov�neo �
CES
License NumUer Lia Class � �
LIMITED TIME USE
Contxactoi . Date_ oA*s ow*E
� 1 am exempt&om the licensing requirements as I am a. NSPecrors's
licensed architect ox a xegistered professional en�neer SISE OF No.oP �s�cNaruee
acting in my pxofessionnl capacity fSection 7051,Bus- Ex�sx�na e�oo. ��p STORIES Z
iness and Pcofessions Code}. ��I �+
PRESENT USE oF su��oiNo �,S�dvu T�l F'1NAL APPROVAL �-�!� CJ�—
Lic.ox Reg.No. Date
HOMEOWIVER-BUILDFRDRCLARATION No.oaex�sriHaeu�tinw�s ������ � �U ��� "����f�
wr wno usE
I hereby affum that 1 am axempt fxom the Contractox's
License Law fox Yhe following xeasott(Section 7031.5,Busi- ����.C�
ness and Professions Code): No.PaaK�ne
�I, as owncx of the pxopexty,will do the work 1nd the ^css vxov�nED 2 i ;;e � e ;i
stiucture is not intended ox oPPered foi sale (Section ��
704A,Business and Pzofessions Code). - , �/ � � ���,��'
CONS'PRUCPLO'.V LENllING AGENCY PROPoseo uss oF eu�r.mNc LLa.�✓1, m e e 4 n
u.,����
I hexehY o£fixm that there is a conskruction landing agene
Y Q B,�F'.='�.'3''�
fox the pexfotmance of the woxk for which this permit is
' issued(Sec.3097,Civ.C.). _ .
Lender's Name � '
� POSED M4X.0
Lenders Ad�ess
PERMIT FEE (�,CIp
I cextify that I have read this application and state that the
above infoxmation is coxzect.I agree cn comply with all County ISSUANCE FEE ���}
ord'uiances and State laws xelating to bullding construction, '
und hexeby authoxve zePresentutives of this County to enter TOTAL FEE �(�, . ,
upo y�g/al�ove� ioned p ope for iiispection purposes.
�/ /y� SEE REVERSE 1�OR EXPLANATORY LArGUAGE
r6/'�r d"
Signatur exm ttee Date
- INSPECTOR'S NOTES � �t'F�VEIZ-BUI;'P/EF$G�C.L�T2�A7IQIN �
"'�`�` -- """�""""'" 1 hereUy all7rrn tfmt I am e�eaipt Gore�tlie Contractoi'x
Liccnse Law Tor the follo�ving reason,�S�=rtio;i 'r137,5.
. - _ — Busi:ress and t'r�ofes,siorzs CodeC flnv <�itr or coco.n..
� , �_. .- . . � . , _ �Ju� quirer F ii m <c�1 t�ct nt � .nprore.
'INSPECTOft'S
APPROVALS DATF (I I.10/11_ OP :eril .Y �S!rl CYe j.loP J S ZS�Ssu t'e.
SIGNATURE .
a�so cqurres fl npphcmzt !o nJi ��m� . j d a
�Rq�LEa�use - � � � — srS�tea str enae;t tiat Fe e (erisod �sir�7t r 71.��
p_A�ETV PF_RMIT � � ' ' proi s'ons �J IJ t r[c�o. s I ier�se L CI nter 9
` . .
� � . (corrvnei enig wi h Sccnan �00) of Dz isu�i 3 n� nc
�evluoRaRY I3usiie s r�.id Pr tec�ioits Cod � �r rFtat ]ie as exeiv�(�t
rr�ucrURe npPaOve� j $ - Jaer f�n a+acf th b sis`nr 7, n�leged exernatemi 4nv
� .EMPORARV I �—� vio[ar+onc,`Seaho.z 031Sby,enyappi.c¢.lfnrape�rn�t
STftUCTUREREft�OVF_D ' � E . _ ` � .
�� subjects dae applaea;et to a cr-il pe�valty of not n:ore[fwrz
_�. ,five ltundred dc1!¢rs�$500�.
i � ❑1,as owr.ei of tlie property�vi11 do U�e woik,a�.d
I . the strur.tixre is not utl.ended ox offered fox sale.
FiN.4�AnPRovA� � � �� � ` ��� ` (Sec. 7044, Basi�iess nnd Pro(e,csions Code: The Cors-
�� — irr�c(.r's Cireixse L¢w does noL appli� Ln me owrre7 of
� ' � � ` " � properri udao b¢�ilds o�'fmproves thrrewi,and who does
. � s«c1a mork himself provided that sucl� rnaprovenie�xte
` . . . . � . .- � ��:�'�'`� �` are not intenled a��af�ered jor s¢le. l; leowexer, the
ba�ildi.ng or irtiproveramit is s�ld withirt one year of
conxpletion, the ou»zer-bx�il�Aer wall have Phe btu'den
of proring that he did ivat build or improve for the
purpnse of�s�ule.J
I am exempt uncier Sec. ,
� � � �� � B Iz P.C.for l'tiis reason—
� � D�te _
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� ;Nsaecre�s r:o�es
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