HomeMy Public PortalAbout5232 BARELA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 8751(11-84) MISCELLANEOUS APPLICATIONI laffirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insureure,, o or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.).
PolicyNo.-Company BUILDING J�
P FOR APP LI CANT TO FILL IN ADDRESS
Certified copy is hereby furnished. BUILDING � LOCALITY
ADDRESS ��JII
0 Certified copy is filed with the county building inspection LOCALITY �- NEARES
department. / CROSS ST 1l
Date Applicant NEAREST /� /J DISTRICT NO GROUP T E PROCESSED BY
CROSS S p/ • je A ¢, , • D O _� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL SO��(J✓l �/ b O
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
No. (.1RCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS. %
(This section need not be completed if the work involved TRACT ff NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) � Iof
SIZE OF LOT J1c./ T �-
I certify that in the performance of the work for which this f o
permit is issued, I shall not employ any person in any manner OWNERz� , EWi]
soD
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP
ADDRESS �_4� CD
Date Applicant �- LU
/J TEL'
�- �` OCCUPANT LOAD
NOTICE TO APPLICANT: If, after makingthis Certificate of CITY L No. O_
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,-you must forth- APPCtATION FOR EXIT HARDWARE:
with comply with such provisions oI 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 SAFETY PERMIT LJ 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 � {
L
effect. PARKING�0/V SPACES REq^D D PROVIDED O
License Number Lie. 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 r NO. OF /I INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. �,� / STORIES 7 SIG TURE
iness and Professions Code). n_ ��•
PRESENT USE OF BUILDING FINAL APPROVAL 2 Zl,�/
Lie.or Reg.No. Date Y
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS Q :.i
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
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 `S n `�� � ^�' °-"riViUaj
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC. -
Lender's Address �4C3
I certifythat I have read this application and state that thePERMIT FEE Q•
above information is correct.I agree to comply with all County ISSUANCE FEE �
ordinan and State laws relating to building construction, 7
and eby autl rite re sentatives of this County to enter TOTAL FEE /
u the abov entio pro rty for inspection purposes.
_ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee � Date