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HomeMy Public PortalAbout9967 DUFFY ST_Miscellaneous_07/06/1989 r WORKERS'COMPENSATION DECLARATION - CE 875 (11-84) MISCELLANEOUS APPLKATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a,certificpve of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BuILDRESSING / ADD (Q Certified copy is hereby furnished. BuILDING 7 uF( r ADDRESS24 LOCALITY Certified copy is filed with the county building inspection LOCALITY �L�P/ G �r�/ NEAREST department. L i L y CROSS ST. Date Applicant NEAREST DISTRICT O. GROUP TYPE PROC SED BY CROSS ST. BALD U)/)J f kr _3 CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL7 COMPENSATION INSURANCE DESCRIPTION LOT NO. 1�4 BLOCK MAP HIGHWAY No. (CIRCLE) STATE MAJOR SECOND LOCAL �J NO. OF BLDGS. (This section need not be completed if the work involved TRACT / / OD NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) -7 X 13 O USE OF REST ZE0TR 252 SIZE OF LOT EXISTING BLDG. 7- I certify that in the performance of the work for which this o- permit is issued, I shall not em any person in any manner OWNER A � SVIK LEY �O M 6�xj so as to b co a subject to orker ompen tion Laws. MAIL '0 c OCCUPANCY GROUP \: \ ADDRESS `Tg67 bvt rk' _3 • �' �' C�o Date/ Applica t W NOTICE TO APPLICANT: , of r making this Certificate of CITY TEMPLE C°lf`% nTio� �� 8(�5 8 OCCUPANT LOAD N Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: _ with comply with such provisions or this permit shall beF deemed revoked. TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 effect. �v A)uJ Room PARKING REQ'D pROVID ED SPACES License Number Lic. Class S� e v Z Z LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a Q FROM: TO: licensed architect or a registered professional engineer SIZE OF ` C NO. OF INSP CTOR•S acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. I ®D �•`,� STORIES / SI NATURE iness and Professions Code). ry, \ _-^ Lic.or Reg.No. Date PRESENT USE OF BUILDING -R6—Y1DC-tJ I l A L FINAL APPROVALZ�rzoyZ-Ar HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's ACCT s os License Law for the following reason (Section 7031.5, Busi- MS Vi't"ructure d Professions Code): NO. PARKING 3307 80.50 as owner of the property, will do the work and the SPACES PROVIDED p`l y' 0 is not intended or offered for sale (Section tir 1 ITE 7044,Business and Professions Code). t TOTAL= 80 o 50 PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY _ �a ° D CHECK 80,50 I hereby affirm that there is a construction lending agency ' for the performance of the work for which this permit is _ +.•H1iNI7 111 issued(Sec. 3097,Civ.C.). . I Lender's Name Lender's Address PROPOSED MAX. OCC. •• 4RlS (S_0001 7/ 6/8-9 I certify that I have read this application and state that the PERMIT FEE Q 4342 1 AM 8:33 above information is correct.I agree to comply with all County' ISSUANCE FEE �© < ord' nces and State laws relating to building construction, Q ereby authorize representatives of this County to enter TOTAL FEE p the abov ioned property f rPctn purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � I ignat re of Permittee Da