HomeMy Public PortalAbout5717 PRIMROSE AVE_Miscellaneous_5/23/1995_GARAGE AND WORKSHOP WORKERS'COMPENSATION DECLARATION
CE 875 (i 1-84) MISCELLANEOUS APPLICATION {�
CE 875 LI
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec. 3800,Lab.C.).
PolicyNo. Company BUILDING .�-7,/7 �•
FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished. BUILDING A _
ADDRESS s::F;7/7 LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROS ST.
Date Applicant NEARESTw DISTRICT NO. G$$$OUP TYPE CESSED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR SECOND LOCAL
NOOF BLOGS.
(This section need not be completed if the work involved TRACT 1 NO.W ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF S
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this C:)
permit is issued, I shall not employ any person in any manner OWNER ='
so as to become subject to the Workers' Compensation Laws. MAIL hC OCCUPANCY GROUP -3 0
/ IJV V
Date ADDRESS Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY-T"P11: [ted N 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
(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
SPACES REO'D PROVIDED
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a t� c�
licensed architect or a registered professional engineer SIZE OF NO. OF PROM: To: INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL 7�1
PRESENT USE OF BUILDING /
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS moi=
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ACC °t
License Law for the following reason (Section 7031.5, Busi- 3303 38.65
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED 1 1TEMS
structure is not intended or offered for sale (Section TOTAL 238 . 65
7044,Business and Professions Code). ;/
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK 238.615
I hereby affirm that there is a construction lending agency CHANGE .00
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name WOO-0001 5/23/95
PROPOSED MAX. OCC.
Lender's Address -2 0556 1 AN11;22
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
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL. FEE
upo tl above-mentioned property for in urposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
f�
Signat re of Perm' to Date