HomeMy Public PortalAbout9153 EMPEROR AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C A T I O N
CE 875 (11-84)
insure, y aff errt that I have a certificate of consent to 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 FI LL IN BUILDING C
ADDRESS
FICertified copy is hereby furnished. BUILDING ADDRESS it Q Ave, LOCALITY ^
Certified copy is filed with the county building inspection LOCALITY NEAREST Ft �1
department. (� b CROs ST. ��
Date Applicant NEAREST DISTRICT NO, J GROUP TYPE PR ESSED BY
CROSS ST, EJ C_ �y `SN- 57 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL JS
COMPENSATION INSURANCE DESCRIPTION LOT NO. " BLOCK MAP HIGHWAY
NOOF BLDGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
.
by the permit is for one hundred dollars ($100) or less.) y `A�/ _ EXISTING BLD
USE OF
SIZE OF LOT 4C.", ^ (a,,�G. t
I certify that in the performance of the work for which this r"''t�,e I o
permit is issued, I shall not employ any person in any manner OWNER L U '-C S i E y
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
MAIL '�, � C1
ADDRESS l 3 �+ iE1/�cJ)4 A
Date Applicant -i c~s
NOTICE TO APPLICANT: If, after making this Certificate of CITY S �A'�21c+Z Nc� / 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 be El
revoked. TRAILER USE ❑ GEOLOGY INSPECTION E] 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. PARKING REQ'D PROVIDED
SPACES
License Number Lia Class �u � u� is T`'Rive-LSLIMITED TIME USE
Contractor Date DATE DATE
0 I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. t6�O• (}�►� STORIES I I S NATURE
iness and Professions Code). K\,��cs� FINAL APPROVALV:212PRESENT USE OF BUILDING F
Lic.or Reg.No. Date
I>CST l vS •
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS .^•{.^ y
ON LOT AND USE S '"lY'•'✓I =
I hereby affirm that I am exempt from the Contractor's --_I§;
License Law for the following reason (Section 7031.5, Busi Fo'�ty i i-la l c, cs - - °`
ness and Professions Code): No. PARKING
SPACES PROVIDED '•-'t^
I, as owner of the property, will do the work and the -7"
structure is not intended or offered for sale (Section )'_s - � Za�
7044,Business and Professions Code). _ y. _...
PROPOSED USE OF BUILDING :•4 eL"OrK
CONSTRUCTION LENDING AGENCY 5 `� - OG -•-
Adl
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 t i l-'; t 4_f'
PROPOSED MAX. OCC. •_{•s r
Lender's Address
O�
I certify that I have read this application and state that the PERMIT FEE A-0� r}SS YS•g�n'
above information is correct.I agree to comply with all County ISSUANCE FEE P �
ordinances and State laws relating to building construction, '/
and hereby authorize representatives of this County to enter TOTAL FEE
upon he above-mentiol ed property for inspection purposes.
✓% SEE REVERSE FOR EXPLANATORY LANGUAGE
lZ hL f
Signature of Permittee date
_ COUINTY OF LOS ANGELES
� DEPARTMENT OF PiTBLdO WOES
r—r-, CROFI= Il9-.�.*ORrILTION
Record Eea-ch
from 1933-1954
Build;T Address �,� Iocs.I uY
Tract No. Lcc No. Lot size
Buildnng Permit Issue Baze i--a Dote _
Descri-pt=or Cr wor'r ,
Lc. Fes.
Bui Idn€ Fed^,=t r Issue n
.�s4e Bale F DC.Ve
DescriDti cn oT' wcI_,
Sc. Ft.
Bu,la�nc Few- , ` I�sse Bate r-nal Daze
Descri-pticn o= wcr
Ft.
Building Fnr-L2-t Issse 82ze F'na1 Date
DescT_-p cicz Oi world
Ec. it.
Build;n` FeT^!- r Issue Bete F=na1 Daze
Descrip zi cn o= worl.--
LC.C. " ..
\Cue. I'_1e i rC a�-o €_Jen uaca rte-? �u�ld^rtc %c_-t- �e�C=2s rJm,e��
CCCuia'_'cy T-s_ec.=CL 1s requested and L..ne Zee _Cr -c r s-jec:.c
i c pai no n"vesG1`a7=Cn o= the -p--,operv3 w-- !! be made b? C s
De-ca::,-=en-u.
Lever Fe= Issue Date
Cc=ec.ed to serer i.T s eet. Ls-necticm, Daae
LOW-
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