HomeMy Public PortalAbout9904 DUFFY ST_Miscellaneous__ WORa".;RS'COMPENSAT10N DECLARATION 8
CE
(2-801 MISCELLANEOUS APPLICATION
' CE 875
I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES- BUILDING AND SAFETY DIVISION
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or a certificate of Workers'
Compensation Compenn sation Insurance,or
a certified copy thereof(Sec.'3800, Lab. C.)
Policy No. Company ., _ _ FOR'APPLICANT TO FILL IN euuDlrvG
ADDRESS
❑ Certified copy is hereby furnished. BUILDING n�jD /� LOCALITY
ADDRESS -( { r
❑ Certified copy is filed with the county building inspectionf� Q �` - NEAREST
department. LOCALITY L (7
CROSS ST.
DatC Applicant - NEAREST //�� � A OrSTRIC T,�N/p GR UP TYPE PROC 5 ED BY
CR055 ST. ALDW I k) U�( CONS'./
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL f u �/
COMPENSATION INSURANCE Da5CRIPnoN LOT NO. BLOCK ... .
NO. F BLOGS.
rvO.P Yl.(/I/ (CIRCLE) STATE MAJOR SEGO D LOCAL a
- I'J
(This section need not be completed If the Work involved TRACT NOWO.ON LOT USE ZONE FrECIAL CONDITIONS U
by the permit is for one hundred dollars ($100) or less.) n I
USE OF '`
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which [his n��I /r , ) -
permit is issued, 1 shall not employ any person in any manner wrueR /fir"' �r D . F_
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP,s LU
•
ADDRESS
' .a.-lit 1
Date-.Applicant. ' '" , Z
TEL' , OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY � No.
Exemption, you should become subject to the Workers' ,qpP LIGATION FOR EXIT HARDWARE:
Compensation provisions of the Labor,Code, you must forth- - - -
with comply with Such provisions Or this permit Shall be TRAILER USE❑ GEOLOGY Iry SP.CTl.. No Spec. Knowl. ❑
deemed revoked. _
LICENSED CONTRACTORS DECLARATION' OCCUPANCY INSPECTION' Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEMS BELOW) NO. OF EXITS
- 9 (commencing with Section 7000) of-Division 3 of the Bust- ,
ness and Professions Code, and my license is in full force and PARKING
effect: gulL� I� � y� PACES ' REO'O PROVIDED
License Number Lic.Class QL"I 5'0' ou--r A$�
At / LIMITED TIME USE
Contractor Date !fN I �� Q LLSE 5 AJ OW t4AWCr - .ATE .ATE
FROM: TO:
I am exempt from the licensing requirements as I am a. Y U IL. A.1 4 PFf
licensed architect or a registered professional engineer SIZE OF NO. OF INSP CTOR's
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES NATURE
mass and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date G
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS 3 Q
ON LOT AND USE
I hereby affirm that- I am exempt from•the Contractor's - ' 1.e,e"8 a 50
License Law for the,following reason (Section 7031.5, Busi-
nSPA PROVIDED
RO
ess and Professions Code): Pw _ Q O.i
SPACES ED ', t \, e. a O'�� J, LI
Ell, as owner of the property, will do the work and the
structure is not intended or offered for sale (Sectioris'-,, ' • a y - 1 ,1,11 I�.•_8 5
7044, Business and Professions Code). 'S[,
PROPOSED USE OF BUILDING '1 '
CONSTRUCTION LENDING AGENCY •. . _ ` 'r. ?. y v
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 Namet
PROPOSED MAX. OCC. • , '.\ Y)
Lender's Address PERMIT FEE
I certify that I have read this application and state that the 6&e -
above information is correct. I agree to comply with all'County ISSUANCE FEE '
ordinances and State laws relating to building Construction, TOTAL FEE G�
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspect i n urp�s. SEE REVERSE FOR EXPLANATORY LANGUAGE _
ignature ff rmit� at