HomeMy Public PortalAbout4911 DOREEN AVE_Miscellaneous__ P, p
WAIP S_ KERSPCOMPENSATION DECLARATION 76M444 /7
' CE 875(2-80) MISCELLANEOUS APPLICATION ylu(I
insure, o :a firm that I have a certificate of consent to self COUNTY 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. CompanyFOR APPLICANT TO FILL IN BUILDING f// tatu"_ 6A
r�iut.C.i
ADDRESS
ElCertified copy is hereby furnished. BU'LOING C�/V LOCALITY
O ADDRESS
Certified copy is filed with the county building inspection T
�1 .../ NEARES
department. LOCALITY• � CROSS ST.
Date - Applicant NEAREST //��'J y�y'� DISTRICT NO. GRRR�p�VP IT YP PRO Cj�$5EO BY
C ROSS ST./00(5,& Z C� 1111 CO T.. / /i//,
CERTIFICATE OI:EXEMPTION FROM WORKERS' LEGAL a I("J V (•1p[
COMPENSATION INSURANCE DEsc RIPTON Lor No. BLOCK A IDRwA.NOOF BLDGS.
T
NOP (CIrsCLE) STATE MAJOR SECOND &CAL
.
(This section need not be completed if the work involved TRACT NOW ON LOT US hk 20NE SPECIAL CONDITIONS O
by the permit is for one hundred dollars (5100) or less.) h-'
VSE'OF /L
SIZE OF LOT EXISTING BLDG.
1 certify that i, the performance of the work for which this ) _ 0
permit is issued, I shall not employ any person in any manner OWNER Z"- �_ C _
so as to become subject to the Workers' Compensation Laws. OCCU PANCV,G ROUP.. _ P '' " ' U
MAIL'AO DRESS .. -, „ f. ,/'r'� •, a
LU
Date Applicant rn
r ♦ TEL. ' Z
I.AOTICE TO APPLICANT: If..after making this Certificate of eITY ,� No. Sl� OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLI ATION 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 0 No Spec. Knowl. ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and t
effect. ` PARKING: 'REO'D PROVIDED � .
SPACES '
License Number Lie.Class $^ / - - LIMITED TIME USE
Contractor Date • - DATE . DATE
❑ I am exempt from the licensing requirements as I am a.
licensed architect or a registered professional "engineer SIZE OFno. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES GNwTURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No.-Date-
HOME
o. .Date y
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 2 1 4 9. 9 A
ON LOT AND USE
I;hereby affirm that. I am exempt from the Contractor's
Lice
e e e • i Q
License Law for the following reason (Section 7031.5, Busi- 1
ness and Professions Code):, NO. PARKING -
SPACES PROVIDED 1;�❑ •1a 'I O O aQSO-
_1, as owner of the property, will do the work and the �-
structure is not intended or offered for sale (Section
7044, Business and Professions Code). - - C ` • •e.'e $'Q. 5Q�,
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY - "s 0;208=8'Sl
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is -
issued (Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address A Od
PERMIT FEE V '
I certifv that I have read this application and state that the `OI J-0
above information is correct. 1 agree to comply with all County - ISSUANCE-FEE rte! '
ordinances and State-la relating to building construction, TOTAL FEE q d s '
an by au thoiize repre ntative o is County to enter v V ,
u on tl a ab ve-' tin za p pe Y. or lyiSpection purposes. SEE VF E FOR EXPLANATORY LANGUAGE '
01 X -- iceD=o �5,.�•
Signature of Permittee �"D'^ Date '