HomeMy Public PortalAbout9628 CRAIGLEE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (11-84) M I S^E L LA N EO U S APPLICATION PPLICATI®N
I hereby.4ffirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,'or.a certificate of V)orkers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.Q.
Policy No. - Company' FOR APPLICANT TO FI LL IN BUILDING
ADDRESS
4 C-
Certified copy is hereby furnished. BUILDING 1 i `c� I GL�� .t LOCALITY
AD DR ESS !D O cam.
Certified copy is filed with the county building inspection LOCALITY � t NEAREST
department. � 1 CROss ST.
Date Applicant NEAREST DISTRICT NO. G OUP TYPE OC SSED BY
CROSS ST. ✓e ( L Gv� CONST 1
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO.�.�v—Z,�y� (CIRCLE) STATE MAJOR SECOND LOCAL
NOOF BLDGS.
(This section need not be completed if the work involved TRACT NO.W ON LOT z USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
D® - USE OF
I certify that in the performance of the work fSIZE OF LOT EXISTING BLDG.
or which this V`
permit is issued, I shall not employ any person in any manner OWNER b N � o
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP Q:J
MAIL -
Date Applicant ADDREss (p.'Z P IG +� —�-.
TEL.B C.3
NOTICE TO APPLICANT: If, after making this Certificate of CITY i_� �.�. NO. O ` �S-� ( OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPL CATION FOR ` EXIT HARDWARE: _
Compensation provisions of the Labor Code,,you must forth-
with comply with such provisions or this permit shall be TRAILER USE [J _ GEOLOGY INSPECTION,E] No Spec. Know].
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El
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. PARKIN
SPACES EG Rq'D D PROVIDED
J
License Number Lic. Class LIMITED TIME USE
Contractor Date ' DATE DATE
0 1 am exempt from the licensing requirements as I am a
PROM. TO•
licensed architect or a registered. professional engineer SIZE OF NO. OF INSPECTORS
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IG ATURE
inessand ProfessionsCode). FINAL APPROVAL PRESENT USE OF BUILDING F-0
Lic.or Reg.No. Date Ayaz_),6�
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I 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
F1I, 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). .2 5 5 2 5 A
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING # 0,0 0 0 ,3 0
I hereby affirm that there is a construction lending agency I 0.0 8050 a 5 O
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.Q.
Lender's Name 0 0.0 8 0.5 0 Z)i
PROPOSED MAX. OCC.
Lender's Address 0 9,29-86
PERMIT FEE '74PI certify that I have read this application and state that the
above information is correct. I agree to,comply with all County ISSUANCE FEED
ordinances and State laws relating to building construction, /
and hereby authorize representatives of this County to enter TOTAL FEE
uponthe ve-mentioned pr pe ty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permit Date