HomeMy Public PortalAbout5320 BUTTONS AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
.r.. CE 976 (2-BU) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to sett COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800, b
Policy No. Company", 1L St rh .ta.�\ FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is"hereby furnished. eU1LVINe
wDVRSss in LocwurY ./
Certified copy is filed with he county ding.inspection ..
NEAREST /
dep tt.
rmen��j L°Cwurr�/ tr COS. ST
Date + AppllCant NEAREST °ISTR}CT NO. G OP TYPE Pq O GESS/ED BY
CROSS ST. �/ S CONSL
CERTIFICATE OF EX PTIO FROM WORKERS' LBGAL ° -
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK M P Ic�wA
6 � (cin CLel
SATE MAJOR SEGO OCAL Y
(This section need not be completed if the work involved NO. DF Q BLDGs. USE ZONE SPECIAL CONDITIONS' a
P TRACT NOW ON LOT
by the permit is for one hundred dollars ($100) or less.) USE OF U
SIZE OF LOT EXISTING BLDG. Er
I certify that in the performance of theworkin anv ma this O
permit a issued, 1 shall not employ any person in any manner owrvER ^
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP /(y/ _
ADORES /Y LU
Date Applicant W
NOTICE TO APPLICANT: IL after making this Certificate of q CITY - NOL OCCUPANT LOAD Z
Exemption, 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 USEGEOLOGY INSPECTION
E] ElNo Spec. Knowl.
deemed revoked. -
LICENSED CONTRACTORS DECLARATION - OCCUPANCY INSPECTION Panic Devices ❑
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 Busi-
nessand Professions Code, and my license is in full force and
2ffCCI. REp'° PROVIO E°
SPACES '
License Number:f"i7 J7 Lic.Class fOyt G� ,
LIMITED TIME USE
Contract ] to DATre DATE
❑ 7/�m3exe pt from the li "sing fyuirements as I am a M. T
.licensed architect or a registered professional engineer SIZE OF NO. OF f Bop �+lL. �J YvD - I s OR
acting in my professional capacity (Section 7051, Bus- exlsn No BLDG. STORIES SI ATURE
iness and Professions Code). - FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No. Data
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
1 hereby affirm that- I am exempt from the Contractor's
License Law for the following reason (Section 7031.5. Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED
❑ I, as owner of the.property, will do the work and the ' " z 3;7 a O A
structure is not intended or offered for sale (Section -
7044, Business and Professions Code). - # ° • 3 0
, PROPOSED USE OF BUILDING � i i ..
CONSTRUCTION LENDING AGENCY P - 80.5
0
I hereby affirm that there is a construction lending agency "ee e 80,�50x
for. the performance of the work,for which this permit is o
issued (Sec. 3097.Civ.C.). _ 1 =
Lender's Name PROPOSED mwx: OCC. 0 7. ,88 3
Lender's Address PERMIT FEE Q -
I certifv that I have read this applicationand state [hut the
above information is correct. 1 agree to comply with all County ISSUANCE FEE
ordinances'und State laws relating to building cUOS[rn Cti°Il, TOTgL FEE
and hereby au thorie representatives of this.County to ent
uer �V �
n the above-I nti ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
J
Signa[ a of Permittee Date -