HomeMy Public PortalAbout5009 BALDWIN AVE_Miscellaneous__ (4) WORKERS' COMPENSATION DECLARATION 0-0063DPW 12/90
2MISCELLANEOUS APPLICATION
0-006
I hereby affirm that I have a certificate of consent to. self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a dok-tificate of Workers' Compensation Insurance, or
a certified copy th'er'eof (Sec. 3800, Lab. C.)
Policy No. Company- FOR APPLICANT TO FILL IN BuiLDwG
'
BUILPLNG ADDRESS ADDRESS /J
❑ Certified copy is hereby furnished. p® 6A 1A Iv) h A V L LOCALITY
❑ Certified copy is filed with the county building inspection cizIP /
department: I C/� �e• NEAREST _. } n ._. -
!. CROSS ST. h P(j 5 A
Date Applicant SIZE OF L NO.OF BLDGS.NOW ON LOT DISTRICT NO. 7G P TYPE ESSED BY
fj' CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' /�
TRACT BLOCK LOT NO.
COMPENSATION INSURANCE MAP HIGHWAY
No. (C IRCLe) . STATE MAJOR SECOND LOCAL
(This section need not be completed if the work-involved ASSESSOR MAP BOOK b of PAGE / PARCEL USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) QS�/ 0,�, I V
I certify that in the performance of the work for which this OWNER T L No.
permit is issued, I shall not employ any person in any manner �' �" 1 L w — /0 O.
so as to become subject to the Workers' Compensation Laws. ADD �q, �+ h y-e OCCUPANCY GROUP ._
Date Applicant CIT ) ZIP
NOTICE TO APPLICANT: If; after making this Certificate l e �- r 0 V 'OCCUPANT LOAD
of Exemption, you should become subject to the Workers' APPLICATION FOR
Compensation provisions of the Labor Code,you must forthwith EXIT HARDWARE:
comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ '
revoked. No Spec.Knowl. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION'❑ Panic Devices ❑
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 Business NO.OF EXITS
and Professions Code,-and my license is in full force and effect. A/i
F PARKING• REq'D D PROVIDED O
License Number Lic. ClassSPA CES
Contractor Date LIMITED TIME USE
DATE DATE
❑ I am exempt from the licensing requirements as I am a ! ' FROM: TO:
licensed architect or a registered professional engineer �f-
.acting in my,professional capacity (Section 7051,Business SIZE OF NO.OF INSPECTOR'S
and Professions Code). EXISTING BLDG. STORIES SIGNATURE
LIc. or Reg. No. - -- - -Date PRESENT USE OF BUILDING FINAL APPROVAL .. -
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
. ON LOT AND USE - - 30
I hereby affirm that I am exempt from the Contractor's License AC.CToa
Law for the following reason (Section 7031.5, Business and
Professions Code): NO.PARKING �s3f'iJs , , 24707
SPACES PROVIDED v
❑ I, as owner of the property, will do the work and the 1 ITEMS'
structure is not intended or offered for sale (Section 7044, PROPOSED USE OF BUILDING
Business and Professions Code). TOTAL 242. 70
CONSTRUCTION LENDING AGENCY24.70
I hereby affirm that there is a construction lending agency for �H�GN
the performance of the.work for which this permit is issued PROPOSED MAX.OCC. CHANGE .00
(Sec. 3097, Civ. C.).
Lender's Name APPLICANT(PRINT) TEL NO.
Lender's Address ADDRESS 0000-0601 2/ 6/96
I certify that I have read this application and state that the, 4713 1 ASI 9:20
t; above information is correct. I agree to comply with all County PERMIT FEE
ordinances and State laws relating to building construction,and
ereby authorize representatives of this County to enter upon ISSUANCE FEE ,�O
h above- entioned ro ty for inspection purposes. `t ii77 ///777
TOTAL FEE µ/ 7D -
' `g SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of errnitt Date