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Home My Public Portal About9415 BLACKLEY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875444 (11 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES - -MI' DING 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 Bu1LDIN�i ADDRES ADDR 3 5S CeItlfll'y,l copy is hereby furnished BUILDING LOCALITY E Certified copy is filed with the county building inspection LOCALITY NEAREST department CRosS ST Date Applicant NEAREST DISTRICT NO G OUP TYPE PROCESSED BY CROSS ST iO Y _ CONST T/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY NO NO (CIRCLE) STATE MAJOR SECOND LOCAL OF BLDGS (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit Is for one hundred dollars ($100) or less) - USE OF SIZE OF LOT EXISTING BLDG d 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 `� y so as to become subject to the Workers' Compensation Laws OCCUPANCY GROUP 3 MAIL /�� O ADDRESS �// IZ-3 Date Applicant TEL w NOTICE TO APPLICANT If, after making this Certificate of clr NO OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICXTION FOR EXIT HARDWARE Compensation provisions of the Labor Code,you must forth- with comply with such provisions or this permit shall be TRAILER USEGEOLOGY 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 Lic Class �LG�� LIMITED TIME USE Contractor Date I(rGC1 DATE DATE FROM TO El I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF No OF /�/ INSPECTOR s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES g�'— D 3 - QL/�J SIGNATURE mess and Professions Code) / PRESENT USE,,,3F BUILDING - 12y Lic or Reg No Date FINAL APPROVAL ry HOME OWNER-BUILDER DECLARATION NO of EXISTING BUILDINGSa'8' ON LOT AND USE r3i-C Ta I hereby affirm that I am exempt from the Contractor's <%1f 451 License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING ITENS I, as owner of the property, will do the work and the SPACES PROVIDED AL 234 - 4-5 structure is not intended or offered for sale (Section 7044,Business and Professions Code) i H (_f3 23't=4r CONSTRUCTION LENDING AGENCY PROPOSED Us OF BUILDING CHANGE 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) � 4 Lender's Name [�' '/��3 PROPOSED MAX OCC Lender's Address {, :•. 1 I I o = PERMIT FEE (J 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 Zip, ordinances and State laws relating to building construction, Td hereby representatives of this County to enter TOTAL FEE �9T pon the o -mentioned property fo inspection urpos s � 3 SEE REVERSE FOR EXPLANATORY LANGUAGE ig�tucf Permittee Dat COUNT' OF LOS ANGELES ]DEPARTMENT OF PUBLIC WORKS MICROFILM INFORMATION Record Search Building Address ` Locality-===-�-. � Tract No. '- Lot No. Lot Size 5 /SD Building Permit # 3 Issue Date. -� U Final Date U Description of work.I�GAJ i In /lam , Sq Ft Building Permit # Issue Date Final Date Description of work Sq. Ft. Building Permit # Issue Date Final Date Description of work Sq. Ft. Building Permit # Issue Date Final Date Description of work Sq. Ft. Building; Permit # Issue Date Final Date Description of work I Sq. Ft. Note: The information given is taken from Building Permit Records. Unless an Occupancy Inspection is requested and the fee for this inspection is paid, no investigation of the property will be made by this Department. Sewer Permit # Issue Date Connected to sewer in street : Inspection Date a Senior Clerk