HomeMy Public PortalAbout4849 AGNES AVE_Miscellaneous_9/6/1995_ WORKERS COMPENSATION DECLARATION 76M444
CE 875(11 84) M ISCELLANE04S/WPLICATION
I sebaffirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Workers Compensation Insurance
e or
a certified copy thereof(Sec 3800 Lab C) -�7 'fl
Policy No Company FOR APPLICANT TO FILL IN ADDRESS
171 Certified copy is hereby furnished BUILD NG C
ADDRESS S4 Apo Ave em LOCAL TY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department CROs. ST
Date Applicant NEAREST Q� DISTRICT NO GROUP TYPE CESSED BY
CROSSST / CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL D� _� t >
COMPENSATION INSURANCE DESCRIPTION 1 LOT No BLOCK MA H O WAY
NO OF SLOGS O (C C I STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT I NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less)
SIZE OF LOT -1 USE
OTUSE OF
I certify that in the performance of the work for which this 100 EXISTING BLDG �
permit is issued I shall not employ any person in any manner OWNER Q Lan KU0 y
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP
Date ADDRESS Applicant 0 C��
,NOTICE TO APPLICANT If after making this Certificate of CITY a NoL y � OCCUPANT LOAD N
Ex me ption4--you—should become subject to the Workers z
Compensation provisions of the Labor Code you must forth APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permitshall be — TRAILER USE GEOLOGY INSPECTION ❑
deemed revoked ❑_-m ❑ No Spec Knowl
N _...�_ Panic Devices
OCCUPANCY INSPECTION LICENSED CONTRACTORS DECLARATION ���`" _
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi NO OF EXITS
ness and Professions Code and my license is in full force and J� I� I /
effect �� �7�i PARKING REQ D E::= PROVIDED
SPACES
License Number Lic Class
�lvo�
Contractor Date DA LIMITED TIME USEDA 6
171 I am exempt from the licensing requirements as I am a P OM D
licensed architect or a registered professional engineer S ZE OF INSP cTOR S
acting in my professional capacity (Section 7051 Bus EXISTING BLDG STOOR 6S f SI TORE
mess and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING r
Lic or Reg No Date M.5,
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS 3/0
ON LOT AND USE ALIT 4
I hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 70315 Busi 3303 747 7�
ness and Professions Code) NO PARKING b 1 ITEMS
I as owner of the property will do the work and the SPACES PROVIDED `
structure is not intended or offered for sale (Section Tt1TAl. - - �
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILD NG t�`NQE 242
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
Lender s Name 0000_000 1 9/ 6/99
PRO O.ED MAX OCC
Lender s Address 2169 1 AM10 1E
I certify that I have read this application and state that the PERMIT FEE Vol
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter TOTAL FEE
upo the above men ned property for inspection yurposes
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date