HomeMy Public PortalAbout5307 DEGAS AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 111- MISCELLANEOUS APPLICATION
CE 8]5f�l
I hereby affirm that I have a certificate of consent to self .COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION `71u11
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.Q.
Policy No. Company - FOR APPLICANT TO FILL IN BUILD,NO
•`'� 2
ADDRESS - '1i1.Jo'
,Certified copy is hereby furnished. Bu uDlrve gO ?l� v r�)
` ' ,
AD OR ESS ✓ 1/ 'LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST. '
department. .(-, CROSS ST.
Date Applicant - - NEAREST Cl
pISTRtCT NO./ Glf� TYPE, PROCES;^EID BY
CROSS T. J{� U(o/ KK CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL '1
COMPENSATION INSURANCE DESCRIPTION LOT NO. Z BLOCKA
NO (C CCL.) STATE MAJOR SECON LOCAL
NO. OF BLDGS.
(This section need not be completed if the Work Involved TRACT NOW ON LOT USE ONE SPECIAL ONDITIONS- -
by the permit is for one hundred dollars ($100).or less.) 10S or OF
SIZE OF LOTS/� EXISTING BLDG. R' `
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER - v
so as to become subject to the Workers' Compensation Laws. MAIL / �•, 1.000UPANCY,GROUP �
' AO DRESS - , 1i. U
Date Applicant S'Y '9Yi0
NOTICE TO APPLICANT: If, after making this Certificate of CITY 5207 No��o.ne _ OCCUPANT LOAD y
Exemption, you should become subject to the-Workers' z
Compensation provisions of the,Labor Code, you must forth- APPLI ATION,FOR EXIT HARDWARE: _
with comply with such provisions Or this permit .shall be TRAILER USE GEOLOGY INSPECTION ,❑
deemed revoked. El Spec.KnoWl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION - - Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter -
SAFETY PERMIT
9 (commencing with Section 7000) of Division 3-of the Busi- (LIST ITEMS BELOW NO. OF EXITS
ness and Professions Code;and my license is in full force and (+ �J
effect. - Rec .J /` PARKING REO'O PROVIDED
PARKIN
License Number Lic. Class IC -
LIMITED TIME USE
Contractor Date - DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
'icensed architect-or a registered professional engineer SIZE of rvo. of INSPE OR'S
acting in my professional capacity (Section 7051, Bus-. EXISTING BLDG. STORIES SIGN- URE.
lnessffitd Professions Code). FINAL APPROVAL
Lic.'or Reg.•No, - Date PRESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS _
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's - -
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING ..-... _ C Q
1, as owner.of the property, will do-the work and the SPACES PROVIDED C$&fl.5_A
structure is not intended or offered -for sale (Section #.e • e`e130.
7044.Business and Professions Code). 1 I 1_
PROPOSED USE OF BUILDING y,I`eY $„
Q_50,,•,
CONSTRUCTION LENDING AGENCY e,$$,5'.Q,v -
hereby affirm that there is a-constmction lending agency - - - ' '-_' '-
for the performance of the work for which this ? 020 0 I 8,6
'y
P Permit is 1
issued(Sec. 3097,Civ.Q.
Lender's Name
PROPOSED MAX. Dec.
Lender's Address
I certify that I have read this application and state that the PERMIT Fee -
above information is correct. I agree to comply with all County ISSUANCE FEE_ — - -
ord' -an tate law relating to building construction, IJ 1
hereby an orize, r enta i of this County to enter TOTAL FEE
upon the ab a-menti a ro for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perminee Date _