HomeMy Public PortalAbout5464 BALDWIN AVE_Miscellaneous__ WORKERS'COMPENSATIONDECLARATION 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.).
BUILDING
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished. BUILDING , o �y
ADDRESS LOCALITY 1... ,
0 Certified copy is filed with the county building inspection LOCALITY NEAREST ,
department. CROSS ST. 64�_,
Date Applicant NEAREST /�/p DISTRIC �/O G U' TYPE PRO E s D BY
pp CROSS ST. s `r(., %� ° h d� CONST./
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL C�((J��
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SEC D LOCAL
NOOF BLDGS.
(This section need not be completed if the work involved TRACT NO.W ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) 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 �° F ''IG k—) J
so as to become subject to the Workers' Compensation Laws. MAL , 1 , OCCUPANCY GROUP
I
. , 4 Y 1�
Date ADRESs ,Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITYe- ?" N.L OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLIC TION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth
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 X
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000T��Division 3 of the Busi NO. OF EXITS
ness and Professions Code,and my license is in full force and ;.'
effect. J f g/) ni PARKING
SPACES REQ'D PROVIDED
License Number Lic. Class % t f "7 a a
LIMITED TIME USE
Contractor Date CR -k-, I DATE DATE
❑ I am exempt from the licensing requiremerils as I am a
licensed architect or a registered professiona'1 engineer SIZE OF NO. OF FROM: To: INSPECTOR s
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
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
0 I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section 51 0.4 R
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING # e e Y e 30
I hereby affirm that there is a construction lending agency I o - 8050
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). • e e 8 0,5 0 5:
Lender's Name
Lender's Address ?
PROPOSED MAX. OCC. 7,,2 2_8 6
` ,oo
PERMIT FEE (f
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 �a "
ordinances and State laws relating to building construction,
and hereb a}i horize representatives of this County to enter TOTAL FEE YO l� ,y
upon th ab 'e mentio ed prop 1 spection purposes.
/ _ ?,_ REVERSE FOR EXPLANATORY LANGUAGE
Umua,
igna re of Permittee Date
..