HomeMy WebLinkAbout1387A � 1VORFEIlS'COnfPENSATIONllL•CLARATIOY 7EM444 -
�Ee,s,Z.$o, MISCELLANEOUS APPLICATION �
, 1 hereby affirm thar l ha��e a certificate or co�sent to s��t COUNTY OF LOS ANGELES [3UILDING AND SAFETY DIVISION
� insure,or a certiticate of l4brkers'Compensation Insurance,or �
a certified copy[hereof(Sec.3800,Lab.C.)
Pol(cy No. Company FOR APPLICANTTO FILL IN �'�` /5
1 Q DORESS
Certified copy is here6y furnished. eu��o�Ho �ocwurr �/J��
'. ❑ AO�RL43 � ` /'� F/C�4/1
Certified copy is(iled with the counry building insDec[ion NEAFEST
departmenL �ocwurr D R� ewoss sr.
i Date Applicant <noss sr. rj a � ��� ie*wicr rvo. cwoun co e o Eo or
� � -3
� ' CERTIFICATG OF EXEhiP7ION 1'RO�1 LVOItKERS' �sca� _
pLSCRIPTION LOT NU. . OLOCK Mw O 1 }
• com�veNs.anoN�nsua,�NCL hp� /3 (C Ac�E� STATE MAIOq SECONO LOCAL a
NOo�OOF 9LOG5.
- (7'his section need not be completed if the work inrnlved tR„�r N LOT USE ZON6 SVECI0.L<ONDITIONS O
by the permit is for one hundred dollars(5100) or 1essJ V
USE OP
SIZE OF LOT EXISTING BLDG.
� 1 cenify[hat in[he perforniance of the wotk for which this Q
� permit is issued,I shall nnt employ any person in any manner OWrvER '� � r u � � U
' so as to become subjeC[to the 1Yorkers'Compensation Laws. Mp�� . OC6UPANCY GROUP W
�� Date Applicant owess �m�_ � ' a
w o u�
� �E`' OCCUPANTLOAD �
'. NOTICE TO ANYLICr\NT:lt,af[cr making this Ccrtificate of eirr � rvo. ,f= O�G
. Gxemption, you should become�subject ta the Workers' qppUCATION FOR EXITHARDWARE:
Compensation provisions of the LBIJD[Code,you must forth-
with eomply with such pro�isions or this Dermit shall be TRAILER use GEDLOGV vECT10N �
❑ ❑ No Spec.Knowl. ❑
� deemed revoked. ❑
I� LICENSEU CONTRACTORS DECLARATION' rnncr�rvsrecnan Pdnic Devices ,
�, 1 hereby affirm Ihat I am Iicensel under provisions of Chapter SAFETY PERMIT q (LIST ITEMS OELOW� �
9(cummencing with Section 7000)of Division 3 of the�OSI- , NO,OF ex�rs
� ness and Professions Code,and my license is in full force and ' �J—r��, wKirve.
� effect. "--__ SPACES � REp�D � PROVIOLO �
� License Number �T_ Lic.Class
UMITEO TIME USE
� Contraclor�_ Date owre o.re
� 1 am exempt from�he licensing requirements us 1 am a ,
licensed architect or a re6�itered professional engineer s�za ov . no.oP �NSPECTOR�S
�acting in my pmfessional capacity (Settion 7OS1� OIIS� L%ISTING 13LDG. STORIE9 SIGNATUxE
� inessand F'rnfessionsCode). rneseHr ose or auuo�ne . FINAL APPROVAL y_ ��_�S
Lit,or Iteg,No. Date
HO�fE O\VYLR-BUILDBIt DGCLAItAT[ON �H'Lor wNo usc ouuc�Hcs �� ,3 G'"J A
� 1 hereby affirm that•I am exempt from the Cantractor's $$ � � �`�t
License La�v for[he foliowing reason (Section 7031.5.DUSI- HQ pAa�c�Na 'I ' '�i Q..r7� �
ness and Yrotessions Code): � svacEs PROYIOEO �
_ � I, as ox�ner of the property,�vill do the work and the . . • • •a G J Q�
structure is not intended or offered for sule (Section �2� � —8 5
7044,Business and Yrofessions Code). ,
� PROPOSED USE OP 9UILOING
CONSTItUCTION LL'ND[NG AG[NCY
1 here6y affirm [h�t ihere is a construction IenJing agency -
. for the performance of ihe wurk for ��hich this permit is
� issued(Sec.3097,Civ.C.).
. Lender's Name x
rworosen m .occ. -
Lender'sAddress PERMITFEE � U .
' I certi(y�that I have read this application and stute ihat the O� .
� above information is currect.I agree[o compiy tVlih all COunty �SSVANCE FEE
� ordinances and S[ate Io�cs rela[ing to builJing cunslruciion, TOTA{.FEE .$�
and hcreby au[horize representatives of this County to enter �.
upon the abovrJne�ned proper[y for inspection purposes. SEE RL'VEIiSL I�ON EXYLANATORY LANGUAGE ' � _
��l�l � !/ A
Y,�C/t. �e��.,...�.f.�XR.� / O�S'S
Sign ure of Fermiqee Date -
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