HomeMy Public PortalAbout4822 AGNES AVE_Miscellaneous_3/17/1986_add fam rm WORKERS COMPENSATION DECLARATION 76M444 MISCELLANEOUS
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ICE875 (280) MISCELLANEOUS APPLICATION
I hereby afcir t that I nave a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
• insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C) '
Policy No Company FOR APPLICANT TO FILL IN ADD ESS4/if 22
4144w. -
❑ Certified copy is hereby furnished BUILDING a LOCALITY
E] certified
J
Certified copy Is filed with the county building Inspection
LOCALITY NEAREST
department / CROSS ST
Date Applicant I NEAREST DISTRICT 2Q{� GR UP TYPE PROC S BY
CROSS ST U�( —� CONS
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL (� I/
COMPENSATION INSURANCE DESCRIPTION LOT NO — BLOCK —_ MA ry GHWAY }
NO (C RC E) STATE MAJOR SECOND OCAL
Q�
NO OF LOGS O
(This section need not be completed If the Work Involved TRACT �� NOW ON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less)
USE OF
I certifythat to the SIZE OF LOT EXI NG BLDG Cr
performance of the work for which this
permit is Issued I shall not employ any person in any manner OWNER U
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP LU
AD OR09 X IM]S R CL
Date Applicant
NOTICE TO APPLICANT If after making this Certificate of CITY �TioL OCCUPANT LOAD z
Ir
Exemption you should become subject to the Workers APALICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you must forth
with comply With Such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION C1NO Spec Knowl ❑
deemed revoked ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ef Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) f ❑
9 (commencing with Section 7000)of Division 3 of the Busl t NO OF EXITS
ness and Professions Code and my license Is In full force andPARKING
effect SPACES REQ D PROVIDED
License Number Llc Class i
LIMITED TIME USE
Contractor Date DATE DATE
❑ FROM TO
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OFNo OF INSPECTOR S
acting In my professional capacity (Section 7051 Bus EXISTING BLDG STORIES { GNATURE
iness and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING � 01
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION NO O EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractors '
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) NO PARKING
SPACES PROVIDED
❑ I as owner of the property will do the work and the
structure Is not intended or offered for sale (Section A 4 2 Q.3 A
7044 Business and Professions Code)
PROPOSED USE OF BUILDING ` # O O 01030
CONSTRUCTION LENDING AGENCY 0 0 8 0 5 0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is _-0,0 1. 8 Q Jr 0 U
Issued(Sec 3097 Civ C)
Lender s Name PROPOSED MAX OCC 0317-86
L
Lender s Address PERMIT FEE 10.v
I certify that 1 have read this application and state that the ISSUANCE FEE O I
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction ¢^
and hereby authorize repres tatives of this County to enter TOTAL FEE
upon the a ove me tinned perty for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Ir3-/7-L476
��Iirgnatu�reofl)ermittee Date