HomeMy Public PortalAbout9548 BLACKLEY ST_Miscellaneous__ OF
KERS'COMPENSATION DECLARATION 76M444
` CE 875(11-84) M ISCELLANEOUS APPLICATION {�
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION L1
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.).
BUILDING
Policy No. Company FOR APPLICANT TO FILL IN
ADDRESS
Certified copy is hereby furnished. BUILDING // /
ADDRESS i� K. LOCALITY
Certified copy is filed with the county building inspection LOCALITY j / ,� NEAREST
department. .(� �/� TTT cRoss sT. /p L) 1.
Date Applicant NEAREST �� DISTRICT O. G UP CO E R C SSED BY
CROSS ST. Y
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O `�
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NO, F BLDGS.
NO. (CIRCLE) STATE MAJOR SECOND LOCA
(This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) S33 USE of
SIZE OF LOT EX
ISTING BLDG. I'ti .�
I certify that in the performance of the work for which this /,. / ��
permit is issued, I shall not employ any person in any manner OWNER b�tCJl t[' /G
so as to b co e subject to the W ers' Comp���$$$sat' n Laws. ADDRESS (� ��f>LeS� OCCUPANCY GROUP �
Q MAIL p
TEL
qxe.pt,.n,
ate / Applicant c3
OTICE T APPLICANT: IfclrY ISNO. W ,' 7QV7 ' OCCUPANT LOAD
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 ❑ 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 I I�
effect. � 00 �- 't� dl- PARKING
SPACES REq'D D PROVIDED
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
0 I am exempt from the licensing requirements as I am a
FROM: ro:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
11
Lie.or Reg.No. Date a
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 31�
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's A I/+F• 7r*
License Law for the following reason (Section 7031.5, Busi- 307 vp r
ness,and Professions Code): NO. PARKING 0'-10
I, as owner of the property, will do the work and the SPACES PROVIDED 1 ITEMS
jstructure is not intended or offered for sale (Section TOTAL �!
7044,Business and Professions Code). OTA
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK
_ 80.50
I hereby affirm that there is a construction lending agency CHANGE X00
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name 0000_00[1 6 f 6�u9
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE �
� � � .. 30? 1 AM $e'07
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 Q
ordinances and State laws relating to building construction,
and hvely
authorize representatives of this County to enter TOTAL FEE
upo h above-mention property for inspection ur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date