HomeMy Public PortalAbout5119 DOREEN AVE_Miscellaneous__ _ WORKERS'COMPENSATION have TI rt DECLARATION ]E 875 M ISCELLANEOUS LICATION
CE 8]E(11-841
I hergby 'affirm that 1 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. Company FOR APPLICANT TO FILL IN BDILDIric
❑ ADORE58 •�,
Certifiedcopy is hereby furnished. BUILORDING
ADLo<w urY
E55
Certified copy is filed with the county building inspection wcwury NEAREST ,
department. �� eM, CR Oss ST.
Date Applicant NEARESTDISTR�T O. GROUP IPE PROCESSED BY
CROSS ST. v CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �r�a
COMPENSATION INSURANCE DESCRIPTIOry LOT No. 4 Bloc% • iONWA
NO.� O D Icw CLel STATE MAJOR SECOND LOCAL
NO. OF DLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) r DSE of
I certify that N SIZE OF LOT E%ISTING the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNKRZAA4 QAJ OWNERP441 Jy
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
wDDRESs e- _ V
Date Applicant ,,,
TEL. OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of C.Tr No.
Exemption, you should become subject to the Workers' � z
Compensation provisions of the Labor Code,you must forth- A LIGATION 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 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
effect. Pw RCESKING RED-- L= PROVIDED
2-CES'
License Number Lic. Class
LIMITED TIME USE
Contractor Date D.TE DATE
ElI am exempt from the licensing requirements as I am a FROM: YO:
licensed architect or a registered professional engineer SIZE OP r ry r b No. of INSPECTOR'.
acting in my,professional capacity (Section 7051, Bus- EZISTING CLOG. N OF SIGNATURE
iness and Professions Code).
p__
PRESENT USE OF BUILDING FINAL APPROVALKYFJ
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS (�1 ,
ON LOT AND USE .(J
1 hereby affirm that I am exempt from the Contractor's ' . Iyi ' A
License Law for the following reason (Section 7031.5, Busi- (y- T
nes.and Professions Code); ,No. FwSPACES PROVIDED RXwe '•,�;i17 17�11[
I, 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).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 00
I hereby affirm tlult there is a construction lending agency Li�Et-"1 ,,Illi
for the performance of the work for which this permit is ( HAN`C ,fiSJ
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address I_IQhlj—i
1 certify that I have read this application and state that the PERMIT FEE Q. 3776 '
above information is correct. I agree to comply with all County ISSUANCE FEE AN r O'Q 1 .;Lr-
I
ordinances and State laws relating to building construction,
and hereby ut Drize representatives oC this County to enter TOTAL FEE ao
upon the o mentioned p petty for inspection purpos9g.
; SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa[u f mittee Da
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