HomeMy WebLinkAbout1108A (5) wORKERS��o�t�ENs�TtoND��LAR,�T�oN �6M444 MISCELLANEOUSAPPLICATION
CE 875(11�94) �
I hereby af(irni that I have a certificate of conrent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,or a cectificate of Norkers Compensation Insurance,or
a certified copy thereoC(Sec.3800,Lab.CJ.
PolicyNo. Company FOR APPLICANTTO FILL IN BUILDING �`
woortess
�Certified copy is hereby furnished. ev��o��c I v �� ��D �OCALiTY � Q�
aooness �
�Cerlsed copy is filed with the county buIlding inspection �acw��rv������p �� (,�I^�� NEAAEST ��� `J\��dV�
department. cnoss sr. �
Date A}1rll(3i1L NEAREST C.' �/^ /��� /� O19TRICT NO, HOVP TYME PROC��Q EO BY
CROSS ST. J�JN.�G.� L-tV�INb � CONST.T _M\\�y�
CERTIPICATE OF EXE�IPTION FROJi NORhERS� LE6AL
V ��\�i7N
CO\1PENSA710N INSURANCE OESCRIPTION LOT NO. BLOCK MA• - - IGXWAY STATE MA)OR 9CCONG IOCAL
NO.OP BLOGS. �o. (cIRCIC)
��115 S2Ct10i1 need not be compieted if[he work involved TRlICT NOW ON lOT USE 2DNE SPeC1AL CONOITION9 -
by the permit is [or one hundred dollus ($!00) or less.) - vse or
StZE OF LOT EXI9TING BLOO. �
I certify that in the performance of the work for which this �d �O �
permit Is issued,I slvlll not employ any person in any mannex �
w as to become subject to the Nockers Compensation Laws. owr+ea OCCUPANCY GROUP � �
Date Applicant no RE45 9'� AJAJb S�12i►�1G �ZbAO �—� �
NOT[CE TO APPLICANT:If,after making this Certificate of ciTv TeL'�(p�•�g� OCCUPANT LOAD W
���� �A(L No. r�n
Exemptian, you should bernme subjeM ta the Norkers' z
Compensation provisions of the Laho:Code,you must forth- APPLICAT�ON FOR � EXIT HARDWARE �
with comply �vith such provisions or this permit SI13II I1B TgA1LER U98 GEOLOGV�NSPECTION �
deemed revoked. � ❑ No Spec.Knowl.
LICENSL•DCONTItACTORSDECLARATION OCCVPANCYINSPECTION PanicDevices �
I hereby affitm tlut I am licensed undex provisions of Chapter SAPBTY PERMIT� �LIST ITCM9 BELOW� a
9(commencir��vith SeMion 7000)of Division 3 of the Busi- / NO,OP EXITS
ness and Professions Code,and my]icense is in full force and �Al1�1� �C(Jp W ��2EQLA�
effect. raxK�na
� S�wCE3 REO'G VROVI06D
License Number Lic.Class snh ' L LIMITEO TIME USE
Contractor Date �716W OF'F'�i2M lT NUMgEYZ�ylol tde�i p,,,a o„r� .
�
�i am exempt&om the licensing requuements as I am a � - _
licensed architect or a registered professional engineer s�ze on no.or INSPECTOR�S
aMing in my professional capacity(Section 7051,Bus-
EXISTING ALD6. STORIE9 3IGNATUFE
i7t0548IIdPtOfe5si0i15COdt). � � FINAI,APPROVAL ,Jr�����fl
Lic.or Reg.No. Date PRE54NT USC OP BVILOIN6 ik�
t ���
HOUE 0\VNER-BU[LDER DECLARATION NO,OP EXISTING HUIL�INGS - ��
DN LOT AND USE � 1) p,, �
[ hereby affirm that I am exempt Gom the Contractoi's ���� �S�`�
License Law tor the following reason(Section 7031.5,Busi- �
ness and ProCessions Code): r,o.r�wrc,na n�s�—k��b I � ���.�
� [,as otmer of the property,will do the wock and the $PAces enovmeo � - lj y�/ ✓6� ni
structure is not intended or offered for sale (Section !-r/P�Ans � �� �j �� � Q H A
7044,Business and Professions Code).
CONSTRUCf10N L�NDING AGENCY PROPOlCD USE Or BVIL�IN6 . . �� • • °J O
I ]�ereby afCvn that thece is a constmction lending agency I • •B U.5�
for the performance of the�vork fox which this pecmit is
issued(Sec.3097,Civ.CJ. • • •�Q.5 Q�
Lcnder's Name - o^
PROPOSED MA%.OCC. O G G��H S
Lendei's Address
PERMIT FEE �
[certil�that I have read this application and state that the /�.
above information Is correct.I agree to comply with all County ISSV ANCE FEE �Q. " ,
ordinances and Sfate laws telati� to building mnstruction, .
and hereby authorize repres tives of this County to enter � Torn�Fee
upo bove-m prop ty for inspection purposes. ' ��
��_8� SEE REVERSE FOR EXPLANATORY LArGUAGE / J �
Signature of Permittee Date � /
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