HomeMy Public PortalAbout4916 AGNES AVE_Miscellaneous_6/20/1984 � I
Ws1RKERS COMPENSATION DECLARATION 76M444 t
rr), '6E875 (280) MISCELLANEOUS APPLICATION -
I hereby affirm that I have cera of consent to self COUNTY OF LOS ANGELES f� Ci BUILDING AND SAFETY DIVISION
In pre or a certificate of Workers Compensation Insurance or e ,
a certified copy thereof(Sec 3800-Lab C) r
Policy No Company d FOR APPLICANT TO FILL IN ADDRESS t +
Certified copy is hereby furnished BUILDING 1/19 S A p LOCALITY ' r
� �' ADDRESS '
❑ Certified copy is filed with the county building inspection ^ y NEAREST r
department * LOCALITY pr i CROSS ST
Date Applicant NEAREST 4 DISTRICT 4GR0 P TYPE PRO SED BY
i f + j h CROSS ST L W 1 1 �.� + CONST i J
CERTIFICATE OF EXEMPTION FROM WORKERS 'LEGAL µ}
r [ DESCRIPTION LOT NO �. BLOCK y I MAP HIGHWAY` 1 1
COMPENSATION INSURANCE r - ' ( ) STATE MAJOR s o D LOCAL a
",_ , S { NO CIRCLE
NO OF BLDGS
(This section"need not be completed if the Work involved TRACT NOW ON LOTUSj: ZQNE SPECIAL CONDITIONS r Q
by the permit is for one'hundred'`dollars ($100) or less) /Lyo`i /] V
1 SIZE OF LOT 10 ,�, USEIOF
EXISTING BLDG �+ > �72
I certify that in the performance of the work for which this 4
permit''is issued "I shall not employ any person in any manner OWNER C R J:(-'Je K W� LI m I 0c
so as to become subject to thepWorkers�Compensation Laws MAIL t OCCUPANCY GROkUP ^ U
/ Date:v d Appl`icanLLi
't 1).�QW d,_ (�7-� ADDRESS 79 �L VIS
�/�C T _ F
OTICE TO APPLICANT If after making this Certificate of carr APPt' VA�'f �3�` NOL _ `� 9 - OCCUPANT LOAD
Exemption 4you-should become subject to tthe Workers i
Compensation provisions of the'Labor Code you must forth APPLICATION FOR EXIT HARDWARE -4 +
with comply with such provisions or this permit Shall be TRAILER USE GEOLOGY INSPECTION `
❑ ❑d .No Spec Knowl ❑ 5
deemed revoked i y Ge fi _ Panic Devices ❑ ;
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION r f ' 1� I
I herebyaffirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO OF EXITS
9 (commencmg with Section 7000) of Division 3 of the Busi _
ness and Professions Code and my license is in full>force and ` PARKf
effect SPACESG
I REO D PROVIDED
' 1
License'Nuniber Lic Class `
�
LIMITED TIME USE
Contractor i Date �wr DATE DATE
Q ¢ J { FROM ., TO
I am exempt from't he requirements requements as I am at _—
licensed architect or a registered professional engineer SIZE OF No OF ;W'
ro s�,
acting in my professional capacity (Section 7051 BUS EXISTING BLDG r e +STORIES 4r SIGNA�RE
mess and Professions Code) w ° _ FINAL APP OVAL 19-/
i^ CfPRESENT USE OF BUILDING �+
t
Lic oraReg No Date � t
z
V ^
\'
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS
ar 2 1 2 7 A ON LOT AND USE
s I,hereby affirm `that I`am exempt from the Contractors ° r yap i a
License Law for-the following reason (Section 7031 5 Busi, r _ o,olo 030
1 ness and Professions Code) ° ti NO PARKING .. ,. . ,. I I, %
SPACES PROVIDED " C Y N
El as owner o 00
f the property will do the-work and,the z P
structure'isnot intended or offered for sale (Section r o 0 0 Q
7044 Business and Professions Code) iPROPOSEDsUSE OF BUILDING ?^ ( yt F II 7 MI i
` 1" 4 - '
p CONSTRUCTION LENDING AGENCY r = � ' ;� � y 0620-84�
I hereby affirm thatrthere is a construction lending agency
for the performance of the work for which this permit is r ,
issued(Sec,3097 Civ C) r ,� < '' + y °p -
Lender s Name F 4= "
I PROPOSED MAX OCC
Lender s Address �' ° Y
. x PERMIT FEE �- / � Y
I certify that I have read this application and state thatti the
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction
and hereby auth0r17e representatives of this County to enter TOTAL FEE
up the bove mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pe V ittee Date