HomeMy Public PortalAbout9932 DUFFY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that &Ijave a certificate of consent to c 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 BUILDING j�
ADDRESS �/
Certified copy is hereby furnished. BUILDINGV v6 LOCALITY
ADDRESS �j
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. //� L cRoss sT. (,
Date Applicant NEAREST G UP TYPE P ES5E D'B
CROSS ST. �Pe �Vv O/(� '� CONS .,
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL C�
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCA
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPEC IAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. 9:
o_
permit is issued, I shall not employ any person in any manner OWNER 0V A L-b
so as to become subject to the Workers' Com ensation ws. MAIL ///�/�//,_ OCCUPANCY GROUP. Ral
0
ADDRESS �j'(/'�✓ �� Q �
Date rb r Applicant ' �� L�LI
NO. OCCUPANT LOAD
NOTICE TO APP CANT: If, after making this C ificate of clrY C�'14 No. obJ – Z.7 z_
Exemption, you should become subject to th Workers' APPLICATION 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 INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El
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 /�
�v ✓ ( S' �I
effect' SPACES
PARKING REQ'D D PROVIDED I
License Number Lic. Class ) — �G0%in3 . lu t LIMITED TIME USE J
Contractor Date F r
DATE DATE
FROM: TO:
❑ I am exempt from the licensing requirements as I am a
.licensed architect or a registered professional engineer SIZEOF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING-BLDG. STORIES S I Gq41TURE
iness and Professions Code).
FINAL APPROVAL
PRESENT USE OF BUILDING '
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 70
ON LOT AND USE _
I hereby affirm that I am exempt from the Contractor's ACCT.0
License Law for the following reason (Section 7031.5, Busi- 3307 80.5
ness and Professions Code): NO. PARKING'
•I ITEMS
14 I, as owner of.the property, will do the work and the SPACES PROVIDED 1_ ITEMS.
i�+
structure is not intended or offered for sale (Section TOTAL 80.m��
7044,Business and Professions Code). 1(
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING CHECK
I hereby affirm that there is a construction lending agency CHANGE .. ,QQ
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name (i L Q//
PROPOSED MAX. OCC. 0000-0001 9/89
Lender's Address (�C
O 868 j AM go1�
I certify that I have read this application and state that the PERMIT FEE 7A10
above information is correct.I agree to comply with all County ISSUANCE FEE D J 0
ordinances and Statelaws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE ,
upon the above-menti ed property for inspection purpose
SEE REVERSE FOR EXPLANATORY LANGUAGE
� 6 _
Signature of Nr ttee Date