HomeMy Public PortalAbout9474 BLACKLEY ST_Miscellaneous__ V
S`� CE 875 (11-84)� WORKERS'COMPENSATIONDECLARATION MISCELLANEOUS APPLICATION
i CE 875
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or -
a certified copy thereof'(Sec. 3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS
FICertified copy is hereby furnished BUILDING
94,74ADDRESS B L A C K L E Y TEMPLE CITY LOCALITY WAL
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST
Date Applicant NEAREST DIS�$,i C7'jd57` GF % T E / PROLE SSE BY
CROSS ST. 44JJ--�, /v'L`AJ/ K NST. v
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION Lor NO BLOCK MAP HIGHWAY
NO (CIRCLE) STATE MAJOR SE CO LOCAL
NO. 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
I certify that in the performance of the work for which this SIZE OF Lor EXISTING BLDG. o
permit is issued, I shall not employ any person in any manner OWNEI�y/�� ��j(�— � i� ''
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP. o
ADDRESS I '
Date Applicant LU.J
NOTICE TO APPLICANT: If, after making this Certificate of CITY NO 7 OCCUPANT LOAD
Exemption, you should become subject to the Workers' zan.(&
APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USEGEO GY INSPECTION ❑
E) E] 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 OCCUPANCY INSPECTION PARKING
SPACES REQ'D E� PROVIDED
License Number Lie. Class 273 %NNX so FT BEDR00M
LIMITED TIME USE
Contractor Date DATE DATE
1
❑ 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 SI ATURE
mess and Professions Code) FINAL APPROVAL G v
PRESENT USE OF BUILDING o
Lie.or Reg No. Date
47'a 0 0
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS Io o 8
ON LOT AND USE _
U
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Busi- Q 09-88
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 wluch this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
' 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 FEEJ
upon th bove-mentioned operty for inspection purposes. Lo
SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Permittee Date