HomeMy Public PortalAbout5011 BALDWIN AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875(11-84) \M I S C E L LA N EO U S APPLICATION
CE 875 L, I
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION IIL JII
insure, or a certificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING
ADDRESS -5 f, L kII ", LOCALITY
ElCertified copy is filed with the county building inspection LOCALITYNEAREST
department. 7- j7 CROSS ST.
Date Applicant NEAREST / // n DISTRICT NO. GROUP TYPE 1PRQQ��E SSED BY
CROSS ST. L �/�/� 4Zj4 S T7 'D f/ �- CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' a
COMPENSATION INSURANCE DE SCR,
LO �� aS BLOCK —� NMA
OP)37 67--0",CR�Ej
STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT61 NOW OON LOT S USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) EK 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 OWNER — ='
so as to become subject to the Workers' Compensation Laws. MAIL G OCCUPANCY GROUP 3 0
ADDRESS - ® U
Date Applicantdye ,y
NOTICE TO APPLICANT: If, after making this Certificate of CITYTTEL.(^?) 2 3 OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLI ATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth
with comply with such provisions or this permit shall be
deemed Ievoked. TRAILER USE EJ TRAILER INSPECTION ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY-INSPECTION ❑
Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busy SAFETY PERMIT E] (LIST ITEMS BELOW) NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. L / PARKING REQ'D D PROVIDED D
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDINGLl 14�-
Lic.or Reg.No. Date JLo-2
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS „ : 3 , •
ON LOT AND USE
Iw {. =.k i
I hereby affirm that I am •exempt from the Contractor's �iti�_� �^-�==•_e_
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
I, as owner of the property, will SPACES PROVIDED do the work and the I_;1"AL
structure is not intended or offered for sale (Section
"-�
7044,Business and Professions Code). T
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.Q. -_
Lender's Name ---- '-{
PROPOSED MAX. OCC. 5D:j23 j• ice'•,-{!i'la '
Lender's Address D I
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
upon th bove-mentio prope ty for inspection purposes.
r SEE REVERSE FOR EXPLANATORY LANGUAGE
I Signature of Permit Date