HomeMy Public PortalAbout8810 ELM AVE_Miscellaneous__ � CDECLARATION S I
,woRSOMPENS IOON71M44
CE 875 (11-84) MISCELLANEOUS APPLICATION
I herby.(firm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or aIertificate of Workers'Compensation Insurance,or
a certifieAcopy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING /�
�+ ADDRESS �/
Certified copy is hereby furnished. BUILDING /� .C��A LOCALITY
ADDRESS �r {� �V�
Certified copy is filed with th county buil in spection � q t NEAREST
LOC ALIT (J
CROSS ST. �� e
de,,��art��m, ent��
Dat; (_Applicant NEAREST ' ` g DISTRICT NO. ROUP TYPE PROCFy$SED BY
CROSS ST. UseA-m— — 5-r�� CONST._ /J y
CERTIFICATE OF EXEMPTVN FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT 2, USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. FJ I
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER Zot+tJ RE'SS nl
so as to become subject to the Workers' Compensation Laws. ^�[a �ALM OCCUPANCY GROUP �
MAIL 88 1..+ . O
Date ADDRESS Applicant `;
W
NOTICE TO APPLICANT: If, after making this Certificate of clrvT P(� C� T O.LZ,gtp 10SO OCCUPANT LOAD
Exemption, you should become subject to the 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 ❑
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. 1 �Q WALL— �RM PARKING
SPACES REQ'D E:= PROVIDED
License Number 512,E Lic. Class C,--Z O
10 2--�1 LIMITED TIME USE
Contractor Date, DATE DATE
FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineerSIZE OF NO. OF I INSPECTOR'S
acting m my professional capacityE
'(Section 7051, Bus- EXISTING BLDG. STORIS SIGNATURE
iness and Professions Code). _
Esl;�. !+'�Jv FINAL APPROVAL
BUILDING IT`
Lic.or Reg.No. Date PRESENT USE OF
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
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 �� '
I, as owner of the property, will do the work and the ACC ,B
structure is not intended or offered for sale (Section
7044,Business and Professions Code). \ 3'101' 4 �i,"!
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING a 'r•-
I ECI'_
I hereby affirm that there is a construction lending agency - '
for the performance of the work for which this permit is T!�!!i20- 5
issued(Sec. 3097,Civ.Q.
CASH
Lender's Name _
PROPOSED MAX. OCC. CHANGEa0 i
Lender's Address -
PERMIT FEE 1n .nQ '
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County ISSUANCE FEE Q
ordinances and State laws relating to building construction,
and hereby authorize epresentatives of this County to enter TOTAL, FEE O I 03 l=Hi '
upon the Bove-ment' ed property for inspection purposes. 11 1+
SQ SEE REVERSE FOR EXPLANATORY LANGUAGE
10-2 ^
Sign u e of Permittee Date �1