HomeMy Public PortalAbout9138 EMPEROR AVE_Miscellaneous__ WORYr ERS'COMPENSATION DECLARATION
CE 875 (11 84) M I SC E L LA N EO U S APPLICATION
CE 875
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,^or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FI LL IN BUILDING / �p
ADDRESS C_
Certified copy is hereby furnished BUILDING
ADDRESS LOCALITY
Certified copy is filed with the county building inspection LOCALITYI _ - NEAREST
department CROSS'ST
Date Applicant NEAREST DISTRICT NO OUP TYPE PRO ESSEDIBY
CROSS ST CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION]INS'URANC'E DESCRIPTION LOT NO BLOCK MAP, _21, I IGHWA j
NO OF BLD G3 NO CIRCLE STATE MAJOR SECOND LOCAL `
(This section need not be completed if the work involved TRACT NOW ON LOT US ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less)
SIZE OF LOT USE OFEXISTING BLDG '( `J...
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 CD
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY`GROUP' 3
ADDRESS \ r_� ' �j �
Date Applicant w
NOTICE TO APPLICANT If, after making this Certificate of CITY TNOL OCCUPANT LOAD
Exemption, you should become subject, to the Workers' a
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USE G LOGY INSPECTION No Spec Knowl
deemed revoked Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busr NO OF EXITS
ness and Professions Code, and my license is in full force and I- '
effect ` / / ' PARKING REO'D PROVIDED I
� SPACES
License Number Lrc Class 6 LIMITED TIME USE
Contractor Date DATE DATE
r7I am exempt from the licensing requirements as I am a FROM TO
licensed architect or a registered professional engineer SIZE OF NO OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES S NATURE
mess and Professions Code) FINAL'APPROVAL
PRESENT USE OF BUILDING f
Lrc or Reg No Date
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ;E 6 3 9,
License Law for the following reason (Section 7031 5, Busi-
ness and Professions Code) NO PARKING r o • $
17 I, as owner of the property, will do the work and the SPACES PROVIDED \e o • Q =
structure is not intended or offered for sale (Section
7044,Business and Professions Code) "
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
•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 Name
PROPOSED MAX OCC
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon Pe above-mentioned property for inspection purposes
G�
.r / SEE REVERSE FOR EXPLANATORY LANGUAGE
-. Q�� G
Signature of Permittee Date