HomeMy Public PortalAbout5319 BALDWIN AVE_Miscellaneous__ (2) WORKERS'COMPENSATION DECLARATION 76M444
CE 875,(11-84) MISCELLANEOUS APPLICATION
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.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING 2
ADDRESS
Certified copy is hereby furnished. BUILDING / 1
ADDRESS /I_/
V LOCALITY
D Certified copy is filed with the county building inspection LOCALITY
NEAREST
department. (RM 7 CROSS ST,
Date Applicant NEAREST D/ �N /
/ DIST�ICT N G up, TYPE PROC SED BY
CROSS ST. L [/� /f1 CONSIJ
-
CERTIFICATE OF EXEMPTION.FROM WORKERS' LEGAL �la ✓
COMPENSATION INSURANCE DESCRIPTION LoBLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECO LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT s NOW ON LOT USER-1
NE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) A us OF51
SIZE OF LOT XD X S EXIST7N BLD G.D �/ aI certify that in the performance of the work for which this CCVJJ I' o
permit is issued, I shall not employ any person in any manner OWNER 0 — i,JC—Al q to I YAWA =o
so as to become subject to the Workers' Compensation Laws. _ '
MAIL QC CUPAgNCY:GROUP•.,-
ADDRESS /J'Ol'1 M V[r • ''` 5��,`` �`�, ,\ - U
Date Applicant �
./ �` OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY gpM1Af rpN G TEL"NO. 1 _
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 TRAILER USE D 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)
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 �J/�rm, J v^)'
t
effect• al 0 647 t v PARKING REQ'D PROVIDED
License Number Lie. Class SPACES
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. �6 S� STORIES SIGdATURE
iness and Professions Code). / y
PRESENT USE OF BUILDING t/J FINAL APPROVAL
Lic.or Reg.No. Date
JGZ
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS y�
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-
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED 2/
� , __�, •-� , _
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
PROPOSED USE OF BUILDING
•� ' � ' � -
I hereby affirm that there is a construction lending agency ( �� GZ" ° ..• - ., ,9 5 3,5 AI',
for the performance of the work for which this permit is #+o 0'Q e 3 0,
issued(Sec. 3097,Civ.C.). 'I,c o$,0 50
Lender's Name
PROPOSED MAX. OCC. -.,
Lender's Address .'o D o 8 0,5 0.Cm)
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 0 5, 0 5. 8 8
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon he above-m t ned�operty for inspection purposes.
` SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Ndmittee Date
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