HomeMy Public PortalAbout6012 BURTON AVE_Miscellaneous__ )NORKERS'COMPENSATION DECLARATION CE S74
C 5 (2-80) MISCELLANEOUS APPLICATION {�
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CES74
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I hereby affirmV that I have a certificate of consent to SelfCOUNTY'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 FILL IN BUILDING
ADDRESS L .
Certified copy is hereby furnished. BUILDING LOCALITY
❑ ADD.Es �Y
Certified copy is filed with the county building inspection NEAREST cROSs ST.
department. LOCALITY /A wAi mss -
(A-61 C14I'i e � v/VYN-rr
Date Applicant NEAREST OISTRIC$ O. GR UP TYPE PROCE E BY
CROSS ST. Q/ /ter /f(o� CONST. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL - J t� V
COMPENSATION INSURANCE'- OESCRI PTI ON LOT NO. .— ' BLO<K MA I�„„,,, }
ry0. STATE MAJOR SEC NO LOCAL d
NO. OF BLOCS. O
(Till$ section need,not be completed If ttlC WUrk involved TRACT NOW ON LOT US�LZONE SPECIAL CONDITIONS U
by the permit is for one hundred dollars (SI00) or less.) / /J / usE oP • j/K/1
SIZE OF LOT Sd x/-r d ESISTING BLDG:
I certify that in the performance of the work for which this O
permit is issued, I shall not employ any person in any manner OWNER r t—i� p 0 re/ . ” -=—/- ---../—J (~j
so as to become subject to the Workers' Compensation Laws. malt. OCCUPANCY GRO"OUP`, - !iJ
ADDRESS �7�
CL
Date - Applicant //�� t^ Y rn
NOTICE TO APPLICANT: If,'after.making this Certificate of CITYIE iC .� l0 No.' �,9^d9G'v OCCUPANT LOAD z
Exemption, you. should become subject to the WBrkers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth- .
with comply with such provisions Or this permit Shall be TRAILE. DSE GEOLOGY INSPECTION
deemed revoked. ❑ ❑ No Spec. Knowl. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices E]
I hereby affirm that I am licensed under provisions of Chapter - SAFETY-PERMIT q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the-Buriness and Professions Code, and my license is in full force and G E S u Til a Y19�/�6 . PARKING
effect. - SPACES REO'. E:= PRONTO EO D
License Number Lie.Class - .SLX A -
Contractor - Date I AVM,*TS
LIMITED TIME USE OPTe
I am exempt from the.licensing requirements as I am a 7
iq licensed architect or a registered professional engineer SIZE OF No. of INSPECTOR'S
R's
acting in my professional capacity (Section 7051. Bus- ExIsn NG BLDG. STORIES IGNwruR
mess and Professions Code). FINAL APPROVAL �/
PRESENT USE OF BUILDING
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF Ex ISTING BUILDINGS
ON LOT AND USE
I hereby affirm that 1 am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING .
SPACES PROVIDED
1, as owner of the property, will do the work and the _
structure is not intended or offered for sale (Section 2(I 2 9.0 A
7044, Business and Professions Code). PROPOSED USE OF BUILDING
g . ... . 30
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency - 1 •�- a 0 50
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.). x
Lender's Name 8 0 5.0 0
. PROPOSED MAX. Dec. -
Lender's Address PERMIT FEE ,01, 0 3 2 5-8 6 ,
V
I certify that I have read this application and-state that the /I
above information is correct. I agree to comply with all County ISSUANCE FEE fv SG
ordinances and State laws relating to building construction, TOTAL FEE /� �r
and hereby authorize representatives of this County to enter V �7
[ ur}] nb�me�nedipTrylerty for inspec't'ion .purposes! SEE REVERSE FOR EXPLANATORY LANGUAGE
LAC (/ / T co-rsli 3 219 CL1
Signature of Permittee Date