HomeMy Public PortalAbout5205 DOREEN AVE_Miscellaneous__ WORKE^,S:COMPAN SATIONbECLA RATION '76M444 -' -
MISCELLANEOUS'CE 875 (2-80) . ` 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 U
insure;br a certificate of Workers`Coinj;emsation.Insurance,or
a certified.copy thereof(Sec: 3800, Lab.C.) - q'
Policy No. Company FOR APPLICANT TO FILL IN '2�S- .euu.DIN6
. .ADDRESS �.
Certified copy is hereby furnished. - SI C Loc ALITY
AD OREBS 5d,05 L)oRee//
Certified copy is filed with the county building inspection N AREST
department. - LOCALITY* —TEM;PGE GDrT CRo ss sT: "
NEAREST DISTRICT NO. G OVP�
Date Applicant - ry ryE PRoc o By
• CROSS Sr. Fq--Fn KEY mw- 61,
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' CE RTI PICATE OF EXEMPTION FROM WORKERS' LEGAL 'SiVV
DES:RIPTION LOT.NO. BLOCK1. ''— .}
COMPENSATION INSURANCE ' _ O. 2O� ( CLE) STATE MAJOR SEGO LOCAL p•
NO.-O N LOT S. -O
S (T'b15.5('CtlOn need not be completed IC the work'involved� TRACT ,. � Now ON LOT QT� U$E'�ON� SPECIAL CONDITIONS U
by 'the permit is for one hundred dollars ($100) or.less.) tr
USK OF I(YJ' -SIZE .1 LOT �' EXISTING BLOG6'V6
I certify that in the performance of the work for which this �[ 0
permit,is Issued, I shall not employ any person in any manner owrvER MEL✓I'4 of '�IRGr•Jt9 r7f1RT _
so'as to become;subject to the Workers'.Compensation-Laws. _ °t,', OCCUPANCY GROUPS _ UW
MAIL
• • AD DRE55 S7oS - Do REEK 'r h
Date - Applicant .- t
'TEL.B/8'.YY4'9/Sy,: I �. _ Z
NOTICE'TO APPLICANT: If, after,me king'this Certificate of IT E p �/T ^'�RIJ-XL'?-6 0/' UCCUPANT LOAD
Exemption, .you, should become 'subject to the Workers' APPLICATION FOR EXIT HARDWARE:DW ARE:
Compensation.provisions of the Labor Code, you mustforth- . - . . '. '
with:comply with, such, provisions or, this permit _shall be TRAILER USE 'GEOLOGY INSPECTION No Spec.'Knowl. Ej
deemed revoked. "y _" ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ®' Panic Devices -
Ihereby affirm tha[ I am IICfn$fd under prOVl$IOn$Of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) ry0. OF E%ITS
9, (commencing with Section 7000) of Division,3'Of the Busi-
ness-and Professions Code, and my license,is in full force and PARKING
effect. 1 IIPACES ' REO':O PROMOED i
License Number 4 o Lic. Class - LIMITEU TIME USE
ContractorDate _ TE DATE
I am,exempt from the licensing requirements as=d am a. - - - '
• 'licensed architect"or a registered professional''engineer SIZE OF NO. of ..IrvsP ATow's
acting,in my professional capacity (Section 7051. Bus- EXISTING BLDG. STORIES 1 rvAru RE
. .. r
' iness and Professions Code). - PRESENT USE OF BUILDING DW '" FINAL APPROVAL
akz
Lic,or Reg.No. Date -HOME OWNER-BUILDER DECLARATION NO.of EXISTING BUILDINGS y
ON LOT AND USE �•
'I hereby 'affirm that• I am exempt from the Contractor's -
'License Law for the following reason (Section;7031.5, Busi:
ness and Professions Code); NO. PARKING - - -
- - SPACES PROVIDED
O I, as owner of the property, will do the work and the
.structure is not mtentledl or offered .for sale (Section �:Q Q 5,S A
ff
7044, Business and Professions Code): n - ,
PROPOSED USE.OF BUILDING -✓W� ", M 3�J O
-' CONSTRUCTION LENDING AGENCY _
I hereby affirm that there is a construction lending agency' _ Pis
for theperformance of the work for which this permit is o(-� ) 8 aS
issued (Sec. 3097,Civ. C.).
Lenders Name PROPOSED .....Dec.
Lender's Address PERMIT. FEE f! "
I certify that I have read this application and state that the' Sl)
above information is correct. I agree to comply with all County I ISSUANCE FEE (l ,
ordinances and. State laws •relating to building construction, I TOTAL FEE -
and hereby authorize representatives of this County to enter -
�uphm�he above-mentionegg property for inspection purposes. r SEE REVERSE FOR EXPLANATORY LANGUAGE .,
lrs,a1�:,.,'
Signa,01re of Permittee D to q -