HomeMy Public PortalAbout9015 ACASO DR_Miscellaneous_3/11/1991_new two story WQRK£RS'•COMPENSATION DECLARATION CE 8454(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certifier copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING Ods-- c�1 /
ADDRESS �l LOCALITY
Certified copy is filed with the county building inspection LOCALITY
-�^' C[� e/ NEAREST
department. / 7 CROSS ST.
Date Applicant NEAREST DISTRI T NO GgOUP TYPE PROCESSED BY
CROSS ST. (� 7- '!`jam/ 3 T NK
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) oQ USE of SIZE OF LOT /y- EXISTING BLDG.
I.certify that in the performance of the work for which this rr � W `A/ �/ d
p�rmit is issued, I shall not employ any person in any manner OWNER rj(/�v—S vV� y
so,as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP 3 0
MAIL
ADDRESS
Date Applicant _ c~s
NOTICE TO APPLICANT: If, after making this Certificate of CITY OCCUPANT LOAD N
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
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 andF
effect. �lnl PARKING SPACES REQ'D PROVIDED
License Number Lic. Class LIMITED TIME USE
Contractor f Date !!ll // - /y A O DATE DATE
p b Y !/ -7. // -6 �//.//I FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTORS
t I
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. I(hgaQ� STORIES SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL T (/
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGSON LOT AND USE
I hereby affirm that I am exempt from the Contractor's93F 00
License Law for the following reason (Section 7031.5, Busi- 17 n GI d E }; i_."
ness and Professions Code): No. PARKING CHECK -.00
I, as owner of the property, will do the work and the SPACES PROVIDED V��r,�(�L
structure is not intended or offered for sale (Section Z Hr, - E;
7044,Business and Professions Code). a "-lj€- it AR011Z F`:a
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency G�
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
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,
and hereby authorize representatives of this County to enter TOTAL, FEE
upon the above-men ' erty for inspection purp es.
SEE REVERSE FOR EXPLANATORY LANGUAGE
-i'
Sign u Date