HomeMy Public PortalAbout5022 DOREEN AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION a
1. .. CE CE 87975 (11-64) M ISCELLANEOUS APPLICATION
I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a-certilicate of Workers'Compensation Insurance,or
a certifiedcopy thereof(Sec. 3800,Lab.C.). -
Policy No-. Company FOR APPLICANT TO FI LL I N BUILD[rvc � ) �!�
ADDRESS !!�� GCN V
Q Certified copy is hereby furnished. BUILDING�6.2J Locw urr L
ADDRESS
ElCertified copy is fled with the county building inspection LOCALITY NEAREST
department. CROSS ST. III
Date Applicant NEAREST DIET ICT N RO CONST. P CES BY
CROSS ST. �•
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DE
SCR IPTIOry LOT NO. :35" /O BLOCK D oP p711/0 ��=w raj
H STATE MAJOR SE CON LOCwL
-gyp' NO. OF SLOGS. /
(This section need not be completed if the work involved TRACT 0 NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (5100) or less.) S'p�t/(>o USE OF - 1
SIZE OF LOT EXISTING BLDG.
I certify that d, the performance of the work for which this 1 o
permit is issued, I shall not I "I not employ any person in any manner DINNER /•I 1 /� Z
so as to become subject to the Workers' Compensation Laws. f D a OCCUPANCY GROUP
AOOR ESS �O LZ M1�C h 41w O
Date Applicant C'
TEL. W
NOTICE TO APPLICANT: If, after making this Certificate of clrr T-C, No.Sj S7 OCCUPANT LOAD w
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. _
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter - SAFETY PERMIT ❑ (LIST ITEM 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 /J !
effect I� PARKING REO D PROVIDED
_
License Number Lic. Class SPACES LIMITED TIME USE
Contractor Date " -' SATE DATE
IF I am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer NSIZE OF D. F INSPE crD w's
acting in my professional capacity (Section 7051, Bus- ExIsrlNc BLDG. ST ...
roRDlEs SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL I /
Lic.or Reg.No. Date
:S
HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS
ON LOT AND USE ACU
I hereby affirm that l am exempt from the Contractor's13.00
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING j
El1, as owner of the property, will do the work and the SPACES PROVIDED ITEMS
structure is not intended or offered for sale (Section TOTAL 83 a OQ
7044,Business and Professions Code). PROPOSED USE OF BUILDING CHECK 83.00CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency CHANGE •Ou
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name UOGO-0001 1/30/91]
PROPOSED MAX. OCC.
Lender's Address 8602 1 AM W5`
I certify that 1 have read this application and state that the PERMIT FEE ♦�
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE O
upon the a ve-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig tore o mittee [ Date