HomeMy Public PortalAbout5034 DOREEN AVE_Miscellaneous__ WORKERS',COAIPENSATION DECLARATION . MISCELLAN-EOUS APPLICATION {�
' � CE CE 8875]5(11-841 _ LJ
insure,
affirm that 1 have a certificate of consent to , lf
or COUNTY OF LOS ANGELES.-• n. BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or `, -
a certified copy thereof(Sec:3800,Lab.C.). ,
Policy No. Company FORAPPLICANT'70;FILL-'IN ES
BOORG, Jo�1
ADDRESS
Certified copy is hereby furnished. BUD.R CC '/ \ LOCALITY
Certified copy is filed with the'county building inspection LOCALIT,Y !�. _ C' NEAREST /
department. �%" .e G 47d'O CROSS ST.
Date Applicant NEAREST ') I I` `Y DISTRICA O P TYPE PROCESSED BY
PP CRESS ST, r� _�-".� .�. �i.�'a�' =� �I r/ CONST 1.
CERTIFICATE OF EXEMPTION FROM WORKERS', LE Gw L, \ AJ VVV
COMPENSATION INSURANCE DESCRIPTION LOT NO. - -j, BLOCK A icRwA
NDP IC,w CLHI STA TE'MAJOR
SEC LOCAL
completed if the work involved TRACT �I
(This section need not be com NOW ON
`NO FOF'BeD cs.
p �I�`' O LOT USE NE SPECIAL CONDITIONS
by the permit is for one hundred dollars (5100) or less.) p� - use OF
SIZE OF LOT /V a.00 E%ISTING BLDG. d
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner OWNER Ig2M(yIT/ j ,416 -/ 9✓V r - v
so as tV,1
omubject to the Workers' rnpensation Laws. - p - OCCUPANCY GROUP �" m
mwlL .So�� . 5a-�0 1�2,Q0=_ s ,. o
wA ESS
DatApplicant - �""�/ TEL. ELI
NOTIC APPLICANT: If, termaking this Certificate of CITY NoE OCCUPANT LOAD H
Exemption, you should become subject to [he 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 ❑ No Spec. Knowl. ❑,
deemed revoked. - -
LICENSED CONTRACTORS DECLARATION oCCUPAN CY INSPECTION E) 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 EXITS
ness and Professions Code, and my license is in full force and
PARKING
effect. SPACES R60'D I� PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Dale DATE A
El
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE of NO. of INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg. No. Date p
.HOME OWNER-BUILDER DECLARATION NO. OF Ex ISTING BUILDINGS - - C 8 9 6 3 A
ON LOT AND USE ,
I hereby affirm that I am exempt from theContractor's - '�,• •,e,•..J Q
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No. PARKING •1 e - 8(150
Z1, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Sectio I YC�,r1-/L ����-�E M 1 0 Q LE ST 6 C YU Z E' � ' ' 8.0.5,0:9
7044,Business and Professions Code). ,
50� 'oaess � /Od 02:12'=S8
' CONSTRUCTION LENDING AGENCY PROPOSED usE OP.eu u.D N I/ -
1 hereby affirm that there is a construction lending agency 0c O dAN
for the performance of the work for which this permit is r�/
issued(Sec. 3097,Civ.C:). L r-�/y` N.7AJ ca.0 =b2 M rNG: ess.
Lender's Name '
Lender's Address •3 IJ B wx�J./d1ic. rN�(
PERMIT FEE o � G`"\S
I certify that I have read this application and state that the
above information is correct.1 agree to comply with all County ISSUANCE FEE 0, '
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter - TOTAL FEE IKO ,
upon the, tioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r
z2ll1*r
Signature of Permittee Date ,