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Home My Public Portal About9405 BLACKLEY ST_Miscellaneous__ �O�XF 'COMPENSATION DECLARATION CE 875 (1184) MISCELLANEOUS APPLICATION I hereby affirm that 1 have a ceitifioate 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) Policy No —Company FOR APPLICANT TO FI LL IN BUILDING7 aJ ADDRESS Certified copy is hereby furnished BUILD IN /> (� /e ADDRESS J� LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department P/)I /P CROSS ST Date Applicant NEAREST �/ DISTRICT NO G�QUP TYPE OC SSED ABY CROSS ST PJ a /c.0 �^, p /�./ CONS, ,CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V a v\ COMPENSA'T'ION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY ' NO (CIRCLE) STATE MAJOR SECOND LOC 1 NO OF BLDGS (This section need not be completed if the work involved TRACT NOW ON LOT 1p ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) use OF _ I SIZE OF LOT EXISTING BLDG I certify that in the performance of the work for which this 9:: permit is issued, I shall not employ any person in any manner OWNER o so as to become subject to the Workers' Compensation Laws (/— /�/SC P/ / OCCUPANCY GROUPEU 0 MAIL 9YO...J /(,2c \ /� _ ADDRESS Date Applicant T 11 �GS OCCUPANT LOAD u+ NOTICE TO APPLICANT If, after making this Certificate of clrY P e / No 2 D- Exemption, you should become subject to the Workers' z 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 Knowl deemed revoked , LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices 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 PARKING REq D D PROVIDED D SPACES License Number Lie Class LIMITED TIME USE Contractor Date DATE DATE F] I am exempt from the licensing requirements as I am a L licensed architect or a registered professional engineer SIZE OF No OF FROM TD INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES S NATURE mess and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING Lie or Reg No Date 1 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 r 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) �8 7 2 1 A CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING - I hereby affirm that there is a construction lending agency �# o e o 0 30 for the performance of the work for which this permit is y o 0 8 Q 5`0� issued(Sec 3097,Civ C) Lender's Name o , o $,Q 5 0 ii PROPOSED MAX OCC Lender's Address 0 1. 07-87- 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 the above-mentioned property for inspection purposes I SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76M444 CE 875(11 84) MISCELLANEOUS APPLICATION I hereby of jJm that I have a certificate of consent to selfCOUNTY Of LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a' tificate of Workers'Compensation Insurance,or r a certified copy`thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING ❑ Certified copy is hereby furnished BUILDING ADDRESS ADDRESS � LOCALITY i ❑`dertarti ecopy is filed with the county building inspection LOCALITY p NEAREST p CROSS ST 0 Date Applicant NEAREST ep O DISTRICT NO GROUP CONST PR CE3SED BY CROSS ST `1 off' 3 ,/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �V COMPENSATION INSURANCE DESCRIPTION LOT No Blo cK MAP HIGHWAY NO NO (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed If the work involved TRACT NOW OON LOT F BLD S L,:,[US:EEZONE 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 � permit is issued, I shall not employ any person in any manner OWNER so y so as to become subject to the Workers' Compensation Laws MAOCCUPANCY GROUP ADESS /L IL /�. DR1 C�) Date Applicant G C_s NOTICE TO APPLICANT If, after making this Certificate of CITY ' No OCCUPANT LOAD N Exemption, you should become subject to the Workers' z 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 SKl deemed revoked pec now ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ 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 hcense is in full force and effect PARKING REQ'D PROVIDED � SPACES II��JJ License Number Lic Class K LIMITED TIME USE Contractor Date , 1 S�9 DATE DATE P !!AA V` ❑ I am exempt from the licensing requirements as I am a PROM TO licensed architect or a registered professional engineer SIZE OF NO OF INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE iness and Professions Code) FINAL APPROVAL Llc or Reg No Date PR ESEN USE OF BUILDING TC— l/0- HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE ' I hereby affirm that I am exempt from the Contractor's g r License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) No PARKING ❑ 1, as owner of the property, will do the work and the SPACES PROVIDED TE ' structure is not intended or offered for sale (Section i 7044,Business and Professions Code) - T II HL 227-70 CONSTRUCTION LENDING AGENCY PROPOSED US OF BUILDING S.HErI'; 1 hereby affirm that there is a construction lending agency e - for the performance of the work for which this permit is �I '�� ,CIL) 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 Q i �t� i v:7 above information is correct I agree to comply with all County ISSUANCE FEE - ordinances and State laws relating to building construction, and hereby authorize repesentatives of this County to enter TOTAL FEE C upon the above-m tion property for inspects purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Si a el Onmittee ate i