HomeMy Public PortalAbout5221 BARELA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (11-84) M ISCEL'�ANEOUS APPLICATION
I hereby affirm that I have a certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
BUILDING
Policy No. y Company FOR APPLICANT TO FILL IN ADDRESS /
Certified copy is hereby furnished. BUILDING �7I � i� LOCALITY
ADDRESS G
Certified copy is filed with the county building inspection LOCALITY - 1„ NEAREST
department. FL CROSS ST.
Date Applicant NEAREST ( DISTRICT NO, GROUP TYP P-R, CESSED BY
CROSS ST. )t ��/ CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL '
COMPENSATION INSURANCE DESCRIPTION LOT NO. 63 BLocK MAP HIGHWAY
NO. (C-CLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) ` usa OF
SIZE OF LOT!ox es EXISTING BLDG.
I certify that in the performance of the work for which this CD
permit is issued, I shall not employ any person in any manner OWNER Rob."o 5'(xesS y
so as to become subject to the Workers' Compensation Laws. , OCCUPANCY GROUP 1=
All.ADDRESS I �'
Date Applicant
g 7&-N1'),E &1 TEL ��5� �� � OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY No. v�
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Know[.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION gJ Panic Devices
El
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
effect. RAf 9W CA* PARKING `
SPACES REQ�D PROVIDED
License Number Lic, Class LIMITED TIME USE
Contractor Date DATE DATE
FROM: TD.
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer size OF J .-�z NO. OF ' INCTOR
SIG
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. 1(/��cN 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 --
SPACES PROVIDED - - -
El
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044,Business and Professions Code). a.,. .._
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
PERMIT FEE
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 _
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon he above-men . d property for inspection purposes.
�r���. / f�� SEE REVERSE FOR EXPLANATORY LANGUAGE
-Signature of Permittee Date