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i 1VORKERS'COhiPENSATION DGCLARATION 76M444 �
ICE87512-80) MISCELL:ANEOUS APPLICATION
� n�reby affirm that [ ha��e a ce�t�rcate or consent to se�t COUNTY OF LOS ANGELES E3UILDING AND SAFETY DIVISION
insure,or a certificate of 1Vnrkers'Compensatinn Insurance,or . ,�
a certi�ed copy thereof fSec.1800,Lab.C.)
Nolicy No. Cnmpany FOR APPLICAhT TO FILL IN ' �ooness �'t�G' ��
� Certified copy is hereby furnished. ev�co�nc � `\ LOCAIITY '^•1
OA��AE„���\!T ,\V N�. Q��
CertiRed Copy is filed with ihe county building inspection NEAREST � �r
deparimenL �ocwurr ` cwoss sr.
Ds[e Appticant NEAREST �" \ O19TRICT NO. ROYn rrne vwOCE55Eo,0V
cwoss sT. �V 1 � car+sr. �,
CERTIFICATE OF FiX1i�1PTION FROM1t NORKERS' LEGAL L� ��� �'��, :--�',
COM1IPL•NSATION INSURANCE �ESCRIPTION �or rvo. �O e�otK .... �cHw,ar �-- -��}
(This section�need not be com leted it the wark involved Na•oF o4ocs.
�CIwCLE� 9TATE MAIOR SECOND�LOCAL a �
P � TRACT '�\\ OW ON LOT G�� U9E ZONE 3PECIAL CONDITIONS O f
by the permit is for one hundred dollars (5100)or IessJ `O lx5�x` �.� ge OF ��
SIZL OP LO'1� �l(ISTING 9LOG. ' 0,�,
I certify that in Ihe performance ot the work for�vhith this • .
permit is isaued,[shall not employ any person In any manner OWNER �S^� � - � U
so ax ro M1ecome subJect fo the�lbrkers'Compensation Laws. Mp�� u �OCCVPANCY GROUP W
OORE99 g�m ' d
Uate Applicant A tn
NOTICE TO APPLICANT:If,after making ihis Certificate of eirr� �� no�� OCCUPANT LOA� z
Ezemption, you should become subject to the lVorkers' AppLICATION FOR � EXIT HARDWARE:
COmpensation pmvisions of ihe Labor Cnde,you must forth-
with comply with suCh provisions or ihis permit shall be TRAILER USE • GEOLOGY INSPCCTION
deemed revnked. � ❑ No Spec.Knowl. ❑
LICFNSFD CONTRACTORS DF.CLARATION OCCUPANCY INSPECTION i Panic Devices ❑
I hereby affirm that I am licensed under provisionsof Chapter 9AFETV PCRMIT� (LIST ITEMS BELOW� NO.OF E%IT9 �
9 (commencing wi[h Sectfon 70D0)of Divisinn 3 of the f3usi- �
ness and protessions Code,anJ my license Is in full torce and
C((QCI. PI�RKING� REO�D � PROVIDEO �
C / SPACES
License Number Lic.Class G��('j�lC�
LIMITED TIME USE
Contractor Date � o�•e o..e
� I am exempt from the licensing rfquirements as I am a �
I�censed architect ur a registere�professionai engineer 512E OF � Ho.oc 1N3PECTOR�$
acting in my pm(essionai _spacity(SeCtion 7051�BU4- E%i3TING o�oe. \�O STORIES SIGNATl1RE
inesSandRofessinnsCode). � � rneseHrvseaFnu��o�nc FINALAPPROVAL
Lic.or Reg.Nn. Date -
HO\tE O\VNER-i3UI1,UEli DECLARATION �O.OF EXISTING 6UILOINGS �� �1 6 3 D A
on wr allo use
I hereby afGrm ihat•I am exempt from Ihe Contractor's �� � ���J�
License La�v fnr the foltowing reason (Section 7031.5,Rusi- .
ness anJ ProfeSsions Code): r+o,v�rtK�nc � �
SPACES PROVIOEO I • •$Q 5 O
� 1, as ou•ner of ihe property,.vill do the work and fhe _ � �
structure is nnt imended or offercd for sale (Section � • • •8 0.5 p c=i
7044,Business and Professions Code). •
OPOSEO USE OF BUILOING
07,24-85 '
CONST2UCTION L4:NDING AGL•NCY
I hereby affirm ihal there is a construction Irnding agency "
tor the performance nf the work for�chich ihis prrmit is �
issued(Sec.J097,Civ.C.). � -
Lender's Name
PROPOSED MA%.OCC.
Lender's Address �ERMIT FEE Q.(/U
I certify that 1 have read this application and state that Ihe � . -
above information is correcL I a6ree to comply with all County �SSUnNCE FEE ��,s'-'v
ordinances and State IBIV$relating to buiiding cnnstruclion, iOTAL FEE 80•s�
and hereby autM1orize rep ntatives of this County to enter
u un the above n� t' e operty i ion pur oses� SEF.REV1iItSE FOR EXPLANATORY LANGUAGC
S�K��ature of Permittee ate
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