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Home My Public Portal About5329 BALDWIN AVE_Miscellaneous__i WORKERS'COMPENSATION DECLARA I roN CE 875 (11-84) MISCELLANEOUS APPLICATION ' CE 875 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION mw.re, or a certificate of Workers'Compensation Insurance,or a certified copy thereof Sec. 3800,Lab.C.). m Policy Noompany��/r2ta��55(/[i FOR APPLICANT TO FILL IN BUILDING d �n,� ADDRESS Cr +(L Certified copy is hereby furnished. BUILDING S�2 j �� /� C, ADDRESS / LOCALITY G' Certified copy is filed with the countyb ing inspection LOCALITY NEAR EST department. CROSS ST. Date 9� Applicant NEAREST DISTRICT �p GR UP___TTYPE P CESSED BY CROSS ST. j�D // ,) CONST. / J CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J o ' exC- 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.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER ,p E LI—h-N so as to become subject to the Workers' Compensation Laws. I OCCUPANCY GROUP a Date Applicant J /// EL•` .7 ,� L,J NOTICE TO APPLICANT: If, after making this Certificate of CITY ��( (� vo.t ,_c�fi -jL OCCUPANT LOAD Exemption, you should become subject to the Workers' fti 'i9L__. Compensation provisions of the Labor Code, you must forth- APPLICATION F EXIT HARDWARE: with comply With such provisions Or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code, and my license is in full force and l7llt� � �x� effect. REq•D PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INS TORS acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIW ATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF (STING BUILDINGS C —1 L ON LO AND USE /1�� I hereby affirm that I am exempt from the Contractor's 17 License Law for the following reason (Section 7031.5, Busi- €_i I�l'—.3 ness and Professions Code): No. PARKING r r '. F-1I, as owner of the property, will do the work and the SPACES PROVIDED ' _ 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 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 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 repres es of this County to enter TOTAL FEE upon the above-mentionedropert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -- ignature of Permittee Date WORKERS CUMPENbAIIUN llr(LAKAIIUN 200063DPIW 2/90 MISC:E.LLANEOU5 APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION rmsure or a certificate of Wdrkers Compensation Insurance or i a certified copy thereof (Sec 3800 Lab C) I Policy No Company FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRESS ADDRESS Certified copy is hereby furnished g 53 ,Z q 6,08wir AA e LOCALITY Certified copy is filed with the county building Inspection CITY ZIP department r2--ilft C � C1 R -0 NEAREST CROSS ST Date Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY G CERTIFICATE OF EXEMPTION FROM WORKERS CONST i LOT NO MAP HIGHWAY (�„ COMPENSATION INSURANCE TRACT BLOCK No (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work Involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONESPECIAL CONDITIONS cc by the permit is for one hundred dollars ($100) or less) I I C TEL NO i eify er I certify that in the performance of the work for which this P,�M� hv�a 8}8-53S-S�8 LL permit is issued I shall not employ an} person in any manner ADDRESS _ I so as to become subject to the Workers Compensation Laws OCCUPANCY GROUP tr z Date Applicant CITY ZIP NOTICE TO APPLICANT If after making this Certificate woad of Exemption you should become subject to the Workers APPLICATION FOR OCCUPANT LOAD Compensation provisions of the Labor Code you must forthwith EXIT HARDWARE comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑ � revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[it Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter IfflSAFETY PERMIT❑ (LIST ITEMS BELOW) a I 9(commencing with Section 7000)of Division 3 of the Business ame O 118 eS3 NO OF EXITS and Professions Code and my license is in full force and effect o PARKING REO DD PROVIDED D License Number Lie Class 6(i y It— '-i oL l SPACES i Contractor Date LIMITED TIME USE ❑ I DATE DATE FROM am exempt from the licensing requirements as I am a TO licensed architect or a registered professional engineer acting in my professional capacity(Section 7051 Business SIZE OF BLDG STORIES INSPECTOR TORE and Professions Code) Lic or Reg No Date PRESENT USE OF BUILDING FINAL APPROVAL HOME OWNER BUILDER DECLARATION No OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 70315 Business and Professions Code) NO PARKING ❑ I as owner of the property will do the work and the SPACES PROVIDED structure is not intended or offered for sale(Section 7044 1 PROPOSED USE OF BUILDING Business and Professions Code) CONSTRUCTION LENDING AGENCY i I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued i (See 3097 Civ C) PROPOSED MAX OCC Lender s Name APPLICANT(PRINT) TEL NO Jai Sa }'� SIS-$2f-till Lender s Address ADDRESS I certify that I have read this application and state that the S3 LA Sal d-Wot mile above information is correct I agree to comply with all County � PERMIT FEE I ordinances and State laws relating to building construction and hereby authorize representatives of this County to enter upon ISSUANCE FEE t ,I the above mentioned property for inspection purposes I TOTAL FEE _ g SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date I 11 �r\'(��:{LRS�COh1PL•NSATION DECLARATION 76Maaa I _ MISCELLANEOUS APPLICATION hereby affirm that t have a certificate of consent rself CE 675 (11.84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION � htsure, or a certificate of Workers'Compensation Insurance, e,or _ a certified copy thereof(Sec. 3800. Lab.C.). Policy No. CompBUILDINGany FOR APPLICANT TO FILL IN ADDRESS Certified copy is hereby furnished. BUILDING LocAL1TY iADDRESS i Certified copy is tiled with the county building inspection LOCALITY NEAREST i department. cR use ST. bate_ ___ \ niirtnt ` NEAREST 0ISTR ICT NO. I GROU TYPE y/' pR ESSED BY p. CROSS ST. �� ; CONST.%/ ! (TR 1 IFICATL OF EXEMPTION FROM WORKER" LEGAL 71 COMPENSATION' INSURANCE DESCRIPTION LOT NO. j.LOCK � nwP „IG ww wr NO, ICIRCLC? STATE MAJOR SE OO NO LOCAL - 'T NO. OF HUGS. ( 1)115 section neet! not Ili' completed If rile :Fork Involved TRACT (NOW ON LOT USE �ONE!SPE CIAL CONDITIONS v the permit is for me hundred dollars (5100) of less.) IUSE OF SIZE OF LCT !EXISTING BLDG. '2rzifv that in he ^erfonnance oL :he work for `.vhv:h -.itis rcrmit is issued, I shall nut ernriov iv ae.son in any man ne OWNER L � /'/ Cy bu3__C_il� `` u= :a ;n ?,c:'nn,e �.uhie;: ;n !hc ',:'�,rkers' Cantpensation Law.. MAIL # CCCUPANC`' GRCUP 0 i ADDRESS 4q / TEL' CCC; ;N .P T LO AD I NOTICH f( APPLICANT: _ICANT: If, after makine this Certiut,:ate of CITY � No. fi>:emption, you should becnme subiect to the Workers (',)Inrensation Prov!siOns of :Ire Labor Code• you must forth- / -KATION =0F EXIT HARCVVAR lilt Complc with stl:ll pro%isions or this permit shall be TRAILER USE 7 GEOLOGY INSPECTION J No Spec. Know 1. OCCUPANCY INSPECTION f^ Panic Devices I ' I I(TNISFI)1, ON I RACMRS DEC LA RATION cnbl finn :iia; I ant licensed uncle:provisions of Chapter r, U SAFETY PERMIT y! {LIST ITEMS BELOWi �r.lmmenc;rts with Seaton X000) of Division � of the Bust NO. OF =XITS Hess and Prof"'won, C ole, and m% license is in !oil force a Nafne c bus_ness PARKING SPACES REO'7 i PRO•JIpED �� I LLL��JJJ \Illnhe L1Mi ED TIME USE t,ntr:,c�<`r I`atc_ �wTE �a rE lI I Rorn: =o: i ant escrnpr !rum :he licensing requirements as i am a liccnseti architec: or a registered professionainn et)_eineer SIZE OF i No, of INSPECTOR S actino In illi- rrotesSlUnai c2rocit': (Section 705 . Bus- EXISTING BLDG. STORIES SIG IATE nessandl'rufessiuns(ode?. Ft L ROYAL -11L.I)r Re•=. NO _ —_ Date PRESENT USE OF BUILDING 011 HOMI: OWNi R-iU ILDER DECI.ARATION p7o. OF EXISTING BUILDINGS ON LCT AND USE I herehv affirm that I am exempt from the Contractors i License I.aw for the iutle"mR reason (Section -031..,. Busi- ness :mei Prntessions' odc!: NO. PARKING t, as owner of the aruoer}•. will do the work .and the SPACES PROVIDED structure is not intended or offered for sale (`rection 1044,Business and Professions Code). PROPOSED USE OF BUILDING - CONS IRi.("IION LENDING AGENCY I hereb> affirm that there is a construction lending agency fur the performance of the work for which this permit is issued(Sec. 3097, Civ- .1. :....�•.: .-.....-:. Lender's Narne PROPOSED MAX. OCC. Lender's Address _--- --- _ - .-- -- 25 . 00 I certify that I have mad this application and state that the PERMIT FEE i ahuve information is correct. 1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, i and hereby authorize representatives of this County to enter TOTAL FEE 25 - 00 upnn ill ahu�ve-mention property for inspection purposes. SEE REVERSE FOR EXPLANA'T'ORY LANGUAGE A,i ture: y �//