HomeMy Public PortalAbout5026 DOREEN AVE_Miscellaneous__ �WORKE@S'COh1PENSATION DECLARATION 76M444
87644 (11-841 MISCELLANEOUS APPLICATION
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I hereby affirm 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.),
PolicyNo.—Company BUILDING ,5-�a�
� P FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished. BUILDING
wUDRE55 LOCALITY
Certified copy is filed with the county building inspection wcAurrT1Y�A. / G!I7Y CNEAR
ROS EST L.
department. s sr.
Date Applicant NEAREST Y DISTRICT NO. GROVP TYPE CESSED BY
CROS
5 $T. EL� �DO CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEG.L O
COMPENSATION INSURANCE DESCRIPTION LOT rvo. BLOCK �GNw.
ND,P STATE MAJOR SECOND LOCAL
NO. OF BLOCS.
(This section need not be completed If the work involved TRACT / NOW ON LOT / USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usXIESTDF
6 �� EING BLDG L �/ / Y
I certify that in the performance of the work for which this SIZE OF LOT � d
Permit is issued, I shall not employ any person in any manner OWNER Cj,
so as to become subject to the Workers' Compensation Laws. MAIL
L _ OCCUPANCY GROUP o
ADDRE5551Z,6 �>e
Date Applicant TEL (�
NOTICE TO APPLICANT: If, after making this Certificate of CIT Le A,,; C.,71 No. Q „§" OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: z
Compensation provisions of the Labor Code, you must forth- ❑
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
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 Exlrs
ness and Professions Code, and my license is in full force andr' h p �_r
effect. FAR KING REO'D (� PROVIp Ep
If sACES
License Number Lic. Class (25 Q
//�� -tom— LIMITED TIME USE
Contractor Date LL- ( -1-
owrH HATH
I am exempt from the licensing requirements as I am a TH'
licensed architect or a registered professional engineer SIZE OFNo. OF I PEC OR's
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. 10.,010A, STORIES _�� s ON. RE
iness and Professions Code).
Lic.or Reg.No. Date PRESENT USE OF BUILDING FINAL APPROVAL
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 'r--`. .P
ON LOT AND USE _
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Bust-
Professions Code): NO. PARKING
SPACES PROVIDED I
�I,
as owner of the property, off re the fo work and the
sVucture is not intended or offered for sale (Section -
7044,Business and Professions Code).
14-6 - 50
A. i U i nL
JIr
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING s. Crti 14fI,.Ej_I
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 1
PROPOSED MAX. OCC. {ILII I`i >.I[IIJ i. SLt/'1'JJ41
Lender's Address
PERMITFEE _,i- '
I certify that 1 have read this application and state that the 1 riPIIL'u
above information is correct. 1 agree to comply with all County ISSUANCE FEE „SU
ordinances and State laws relating to building construction,
and hereby authorize re resemat ives of this County to enter TOTAL FEE
u o t}e above✓menti d property for inspection p vposes.
�d / ,,/ SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date