HomeMy Public PortalAbout9468 BLACKLEY ST_Miscellaneous__ WORKERS'-COMPENSATION DECLARATION MISCELLANEOUS APPLICATION .�/ CE CE 875 (11-84)875
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I �,erebv affi in that I have a certificate' of consent to Self COUNTY OF LOS ANGELES BUILDING-AND SAFETY DIVISION
ins�i re, or,a,certificate of-Workers'Compensation Insurance,or 'fl
c I ttfled dopy.thereof(Sec 3800,Lab C.) BUILDING, C C� C'
Polk.y,No. Company FOR APPLICANT TO FI LL IN, V
J
II-I4 ( , -,_ - _ -qqk� 131 . ADDRESS - '
Certified co is herebyfurnished. Bu1LDING
' copy - ADDRESS '� � + LOCALITY U
Certified copy is filed with the county building inspection LOCALITY '
NEAREST
department " T e. C-,-r- CROSS ST.i vejl'�
Date Applicant NEAREST • r� ��� D RIC NO. G TYP CE E BY
CROSS ST. CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL `
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY,
r MA- (CIRCLE) - STATE MAJOR S COND LOCAL
NO. OF BLDG S.
(This section need not be:completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS pI7 I$'—
by •the permit is for one hundred dollars ($100) or.less.) USE OF' ([/�J�' n J�(r9J�J��,
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. r\"', MFif* /�(0 - ro
a,
permit is'issued', I shall'not employ any person in any manner OWNER 3 i ,� `�
so as to become subject to tlfe Workers"Compensation Laws. MAIL OCCUPANCY GROUP o
i r-'
ADDRESS
Date Applicant �� ( TEL'
.
NOTICE TO APPLICANT. If, after making this Certificate of CITY No. `' (.� OCCUPANT LOAD °
Exemption; you should become sub)ect'to°the Workers' APPLI ATION FOR EXIT HARDWARE
Compensation provisions,of the Labor Code,you must forth
wAh comply with such pIOVlSIOris' Or, this permit shall be , TRAILER USE El GEOL06Y INSPECTION No Spec. Knowl.
deemed revoked ° "'
LICENSED CONTRACTORS DECLARATION" OCCUPANCY INSPECTION _', Devices E
I hereby affirm that.1 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 {�s/ �''IIII
effect.. /� Pr\ PARKING REQ'D PROVIDED EJ
SPACES
License Number Lic.,Class I LIMITED TIME USE
Contractor' ' - Date I - DATE - DATE
' FROM TO
I am exempt from the.licensmg 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 / I STORIES SIGNATURE'
.
mess and Professions Code)
' I' FINAL APPROVAL
PRESENT.USE OF?BUILDING `
Lic.or Reg No,. Date " `` I ff.
HOME OWNER BUILDER DECLARATION NO:OF EXISTING BUILDINGS h l-I• I j
' ON LOT AND USE - -
I hereby affirm that I am exempt from the Contractor's i % 6 i _ 1 JTEM "
License Law for the following reason (Section 7031.5, Busi- Ih "_ �-OTAL " sb ®`50
ness and Professions Code):' No PARKING t r-ij 4-
' SPACES PROVIDED ° CHE1_•�t
0 1, as owner
of the property, will do the work the
structure is not intended or offered.for sale (Section _ hH4463E ,CID
7044;Business and Professions Code).
CONSTRUCTION LENDING AGENCYPROPOSED USE of BUILDING
i4_1i4_1 hereby affirm that there is a construction lend,ing agency' Cli 111[1-[ii 111 101j, Al _
for the performance of the.work for.which this-permit is ,-
issued(Sec 3097,Civ.C). L1l:t
Lender'sName
ay i 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+ ,
,apo he
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
(�( L
Signature-of Permittee ate