HomeMy Public PortalAbout4949 AGNES AVE_Miscellaneous_4/1/1987_ WORKERS COMPENSATION DECLARATION76M444 - MISCELLANEOUS APPLICATION
ri t CE 875 (2 80)
I he eby aff that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure or a certificate of Workers
rs Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING S
F1ADDRESS
Certified copy Is hereby furnished ADDRESS LOCALITY J
❑ / 7 Y
Certified copy is filed with the county building inspection NEAREST
department LOCALITY CROSS ST a NQS o. Q
Date Applicant NEAREST DISTRICT NO G UPPP��� T PE / P OC ED BY
CROSS ST H � J' �L� " f� CONS'.T`
CERTIFICATE OF EXEMPTION FROM WORKERS I LEGAL l/ J V
COMPENSATION INSURANCE %SI- DESCRIPTION LOT NO BLOCK MAP / (CIGHWAY
IRCLE) STATE MAJOR SECO D LOCAL ay
NO OF BLDGS o N
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE rECIAL CONDITIONS 0
by the permit is for one hundred dollars ($100) or less) USE OF I U
SIZE OF LOT EXISTING BLDG Cc
I certify that In the performance of the "ork for which this 0
permit is issded I shall not employ any person in any manner OWNER
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP FK7-3
. W
ADDRESS �� d
Date Applicant I TEL fY/
NOTICE TO APPLICANT If after making this Certificate of CITYAg
NO OCCUPANT LOAD z
Exemption you should become subject to the Workers APPLICATION 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❑ No Spec Knowl ❑
deemed revoked Panic Devices ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am hLensed under provisions of Chapter 1 SAFETY PERMIT q (LIST ITEMS BELOW) NO OF EXITS ❑
9 (commencing with Section 7000) of Division 3 of the Busl
ness and Professions Code and my license is in full force and
effect 1 Aov.» PARKING
SPACES REO D D PROVIDED
License Namber Lic Class
04 LIMITED TIME USE
Contractor Date �✓Y +l/ /? DATE DATE
I ElI FROM, TO
I am exempt from the luensing requirements as I am a / (JNI /V O
licensed architect or a registered professional engineer SIZE OF NO OF INSPE TOR S
acting in my professional capaClt) (Section 7051 BUS EXISTING BLDG STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL /J /�
PRESENT USE OF BUILDING -�r�-r�
Llc or Reg No Date (� U
HOME OWNER BUILDER DECLARATION NO EXISTING BUILDINGS y
ON LOO T AND USE A ;26778A
I hereby affirm that I am exempt from the_Contractor s # • e a • 30
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) NO PARKING
SPACES PROVIDED (I � * 8050
❑ I as owner of the property will do the work and the :05structure I. not intended or offered for sale (Section • u • 8 Q 5 0
U
7044 Business and Professions Code) PROPOSED USE OF BUILDING y Q
OU, O1 X87
CONSTRUCTION LENDING AGENCY t
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
PROPOSED MAX OCC
r
Lender s Address PERMIT FEE
c
I certify that I have read this application and state that the
above Information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction 11 C^� r
an v authorize representatives of this County to enter TOTAL FEE v
pon the bove mentioned pro erty f r Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
gna ure of Permittee Date