HomeMy Public PortalAbout10684 ARROWOOD ST_Miscellaneous_1/19/1995_expired permits WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 875
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a spertificAe'of Workers'Compensation Insurance,or
a certiAed copyihereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APP LICANTTO FILL IN ABUILDING O
DDRESS
FICertified copy is hereby furnished. BUILDESSING
ADDROL LOCALITY
❑ Certified copy is filed with the county building inspection LOCALITY NEAREST
department. 1� '. CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE f3`0CESSED BY
CROSS ST. �•^��� // CONST�� (aL
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL r17 ((jam/
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP �' _03O)H
No STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT S NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
Date ADDRESS Applicant LLJ
NOTICE TO APPLICANT: If, after making this Certificate of CITY 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 [JGEOLOGY INSPECTION ❑ No Spec. Know].
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of ChapterSAFETY 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
effect. e- J C0 I PARKING
_ SPACES REQ ID PROVIDED
License Number Lie. Class –4T-6171 '715 11
9 LIMITED TIME USE
�
Contractor Date • DATE DATE
D I am exempt from the licensing requirements as I am a
FROM: TO:
licensed architect or a registered professional engineer SIZE OF No. OF INSP CTO R'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING
<1 q3l
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE ^" $
I hereby affirm that I am exempt from the Contractor's `I`'"`
License Law for the following reason (Section 7031.5, Busi-
nesr<and Professions Code): NO. PARKING _
❑ SPACES PROVIDED L i i-�'I:_;
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section €' ia
A,
7044,Business and Professions Code). r }_ K.
_I
CONSTRUCTION LENDING AGENCY PROPOSED USE F BUILDING
I hereby affirm that there is a construction lending agency �� � L`•= '' }-'
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name �Is4i;; __4jlt`
PROPOSED MAX. OCC.
Lender's Address �-:-?% Air;
PERMIT FEE 6,bi'?' ._ S'hfJ.S°=.+
I certify that I have read this application and state that the pr
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State 1 s relating to building construction, p
and hereby author' rep esentatives of this County to enter TOTAL FEE �_g f
u e above m tione rty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pe itF"11-6
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