HomeMy Public PortalAbout6028 AVON AVE_Miscellaneous_9/8/1987_bay window, extention of fam rm, bd rm WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C AT I O N
I hereby affirm that I have a certificate of consent to self CE 875(1 1 84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,'�a cei�ifiate of Workers'Compensation Insurance,or
a certifiea copy thereof(Sec, 3800,Lab C)
Policy No __Company FOR APPLICANT TO FILL IN ABUILDING
DDRESS �/w (/� ,
Certified copy is hereby furnished BUILDING J�
ADDRESS OZ (/{� r, 9u LOCALITY
❑ department ent (,l�
copy
is filed with the county building inspection LOCALITY NEAREST
eSl � � ST
Date Applicant NEAREST DIS ICTr+,L J G OUP TYPE / PROC SE BY
e . CROSS STpm CONST,/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ' V
COMPENSATION INSURANCE DESCRIPTION LOT NO 3 BLOCK MAP RIGRW AY
r+o (cIRc"E) STATE MAJOR SE CO D LOCAL
NO OF BLr
(This Section need not be completed if the work involved TRACT 03 NOW ON LOT / USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) USE OF
`
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG o
permit is issued, I shall not employ any person in any manner OWNERBeol aam16t _
so as to become subject to the Workers' Compensation Laws OCCUPANCY GROUP1
MAIL
ADDRESS O1 D ` LEE U
Date Applicant n
NOTICE TO APPLICANT If, after making this Certificate of CITY_ Q 1 C'A NoL �� OCCUPANT LOAD
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 USEGEOLOGY INSPECTION
deemed revoked ❑ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION - OCCUPANCY INSPECTION A 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 Busi- NO OF EXITS
ness and Professions Code, and my license is in full force and
effect ` PARKING REQ D PROVIDED
SPACES
License Number Lic Class
Contractor Date it DATE DATE TIME USE DATE
ElI am exempt from the licensing requirements as I am a FROM TO
licensed architect or a registered professional engineer SIZE OF TNo of INSPECTOR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SI NATURE
mess and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING
Lic or Reg No Date
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Busi ;27862A
ness and Professions Code) NO PARKING
0 I, as owner of the property, will do the work and the SPACES PROVIDED # e e • e 3 Q
structure is not intended or offered for sale (Section _ ' N
7044,Business and Professions Code) ° • $Q 5 0
I
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING � � - • °�• $Q 5 O c=.i
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is <� 9 Q$"$7 1
issued(Sec 3097,Civ C) ^
Lender s Name
PROPOSED MAX OCC
Lender's Address _
_711019 1
'
I certify that I have read this application and state that the PERMIT FEE
above information is correct I agree to comply with all County ISSUANCE FEE 1
ordinances and State laws relating to building construction,
and hereby uthorize representatives of this County to enter TOTAL, FEE
upon the abo a mentioned pro ert for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
'4` i ature of Permitt Date