HomeMy Public PortalAbout9228 BLACKLEY ST_Miscellaneous__ WORKERS'COMA ENSATION DECLARATION CE 8754
Is (2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to 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) I
F ' BUILDING
Poli `
cy No Company FOR APPLICANT TO FILL IN
ADDRESS I ,
❑ Certified copy is hereby furnished BUILDING LOCALITY /I ?
ADDRESS G-
❑ Certified copy Is filed with the county building Inspection NEAREST
department LOCALITY cRoss ST ? S
Date Applicant NEAREST \ DISTRICT NO GRO P TYPE PR�CESSE BY
CROSS ST n ( CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
DESCRIPTION LOT NO BLOCK }
COMPENSATION INSURANCE MAP HIGHWAY STATE MAJOR SECOND OCA
NO (CIRCLE) a
(This section, need not be completed if the work Involved No of BLDG -
TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0
by the permit, is for one hundred dollars ($100) or less)
USE OF
SIZE OF LOT x EXISTING BLDG 1` cc
I certify that in the performance of the work for which this 0
permit is Issued, I shall not employ any person in any manner OWNER 0 W
so as to becobled to th orkers' Compens io L3yvs MAIL OCCUPANCY GROUP
t � '
ADDRESS W a
' s
Date me Applicant to
OCCUPANT LOAD Z
NOTICE TO APPLICANT If'after making this Certificate of ciTY pr6 No
Exemption, you should become subject to the Workers' APPLICATION 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 O 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 q (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000),of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect Q PARKING
SPACES REq'D O PROVIDED
License Number LIc Class LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a
FROM TO INSPECTOR'S
licensed architect or a registered professional engineer SIZE'OF No OF /
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE
iness and Professions Code)- PRESENT USE OF BUILDING FINAL APPROVAL
Lic or Reg No Date 6 0 O
No of EXISTING BUILDINGS
HOME OWNER-BUILDER DECLARATION
ON LOT AND USE �(
I hereby affirm that I am exempt from the Contractor's "3 1- 0.9 A
License Law for the following reason (Section 7031 5, Busl
ness and Professions Code No PARKING _ COves/2� # o'D ml• 30
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the - 2 0 o'8 0,,5,0
structure is not intended or offered for sale (Section t
7044, Busmess and Professions Code) 0 0 0 8 Q,3 0=
PROPOSED USE OF BUILDING U
' 1 1
CONSTRUCTION LENDING AGENCY 0.7 3 1 —8 4
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 6
av+ ,
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, TOTAL FEE
and hereby authorize representatives of this County to enter I .1 0
U the above mentio pr - rty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Pe i ee Date