HomeMy Public PortalAbout10764 FAIRVIEW AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11 84) MISCELLANEOUS APPLICATION
CE 875
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insule, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS/07�
Certified copy is hereby furnished BUILDING '..'^�1 LOCALITY, '
ADDRESS O f/�✓`
0 Certified copy is filed with the county building inspection LOCALITY / OF NEAREST �p� /�
department L CROSS STI S t
Date Applicant NEAREST (� DI��TJ��1 O G OIJ� TYPE�y
nEj+J
BY
CROSS ST J {/� i ` CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' V)• `J
LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY
NO (CIRCLE) STATE MAJR ECON LAL
NO OF LDGS OOC
(This section need not be completed if the work involved TRACT NOW ONBLOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less)
USE of
E OF LOT EXISTING BLDG
I
SIZE: 1
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
so as to become subject to the Workers' Compensation LawsMAIL i OCCUPANCY GROUP o
ADDRESS`a F f ate{
Date Applicant ,f,
NOTICE TO APPLICANT If, after making this Certificate of CITYG► i
TEL
��p '!a 62 OCCUPANT LOAD Z
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 USEGEOLOGY INSPECTION ❑
deemed revoked E] ❑ No Spec Know[
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi- SAFETY PERMIT ❑ LIST ITEMS BELOW) NO OF EXITS
ness and Professions Code,and my license is in full force and
effect PARKING REQ D D PROVIDEDIF O
SPACES
License Number Lic Class LIMITED TIME USE
Contractor Date DATE DATE
T S
I am exempt from the licensing requirements as I am a FROM TO
licensed architect or a registered professional engineer SIZE OF NO OF
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES N ENCC U
iness and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING
Lic or Reg No Date HTI�T Ali
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS 3- l iT et(l(
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- T'iTAL. 93 - 00
ness and Professions Code) No PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the 1- E`- • d •�(i
structure is not intended or offered for sale (Section CHANS er 1
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agencyI1 4/23-L
for the performance of the work for which this permit is ham_
issued(Sec 3097,Civ C) 04Z 1 Ate I'e°t,
Lender's Name
1 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 3 Q o
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL. FEE no
upo a above-mentioned property for inspection purposes
W..LM� �� _J3�l�Qa SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date