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Home My Public Portal About5117 AGNES AVE_Miscellaneous_10/16/1987_ ERS COMPENSATION DECLARATION CE 875(11 MISCELLANEOUS APPLICATION I lv by affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 'fl insu a or a certfficate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished BUILDING ADDRESS LOCALITY 0 Certified copy is filed with the county building inspection LOCALITY �� NEAREST department � /cif �j )/ V CROSS ST e(_ DateApplicant NEAREST ^' }�Dl DIST�CT X10 G CONS PROC S E5,MY CROSS ST /V /C •l• l/V�11 oy / CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SE CO LOCAL NO OF BLDGS (This section need not be completed if the work involved TRACT ' / NOW ON LOT US ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) C USE OF r I certify that in the performance of the work for which this SIZE OF LOT 60 X has EXISTING BLDG Sr f permit is issued, I shall not employ a8y person in any manner OWNER so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUPF R �� C= � >� Date Applicant ADDRESS w NOTICE TO APPLICANT If after making this Certificate of CITY NO 8 OCCUPANT LOAD 0- Exemption Exemption 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 permit shall be deemed revoked TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 9 (commencing with Section 7000) of Division 3 of the Busi ❑ (LIST ITEMS BELOW) NO OF EXITS ness and Professions Code and my license is in full force and �j /, �/y� }i effect ✓� y "�!r ,1616I PARKING SPACES REQ D D PROVIDED D License Number Llc Class Aim/O D Contractor Date /� E 5 -7 )( l3 '/.7, LIMITED TIME USE GATE DATE ElI am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer SIZE OF NO CF INSPECTOR S acting in my professional capacity (Section 7051 Bus EXISTING BLDG STORIES SIGNATURE mess and Professions Code) FINAL APPROVAL Llc or Reg No Date PRESENT USE OF BUILDING HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE K + I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Busi # • • • 0 ,30 ness and Professions Code) NO PARKING I as owner of the property will do the work and the SPACES PROVIDED I e - 8050 8050 structure is not intended or offered for sale (Section 7044 Business and Professions Code) x CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING 8 Q 0 v I 0 1,6 8 8 7 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) l Lender s Name PROPOSED MAX OCC Lene Adds PERMIT FEE I cehave read this phcahon and state that the alZoon is corre ee to comply with all County ISSUANCE FEE or State 1 s ting torb ding construction ` andhorize e e ntatives of is County to enter TOTAL FEE upom o roperty o nspectlon p oseSEE REVERSE FOREXPLANATORY LANGUAGE ign e of ermittee Dat