HomeMy Public PortalAbout4927 FIESTA AVE_Miscellaneous__ WORK>,RS'COMPENSATION DECLARATION 76M444
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CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby at erthat 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.).
BUILDING �� �.
PorlicyNo.-Company FOR APPLICANT TO FILL IN `
� ADDRESS
Certified copy is hereby furnished. BUILDING /"ga t'/ �_ LOCALITYz�
ADDRESS S•/ /Y''�_ YG.
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. �G=/yJ CROSS ST.
Date Applicant NEAREST DISTRICT NO. G���jjjOUP COPE NS ��/ CESSED BY
ITY
TAT/ _
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.LEGAL v® /!/
COMPENSATION INSURANCE DESCRIPTION I LOT NO. 9 BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT / S NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG.�y-j4i2.fK�
I certify that in the performance of the work for which this .
permit is issued, I shall not employ any person in any manner OWNER A/ C ��� S y
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP o
MAIL
Date Applicant ADDRESS A /510-1 `l [:��E w
TEL o_
NOTICE TO APPLICANT: If, after making this Certificate of clrY�� ,� eT No. OCCUPANT LOAD
I AIL,-4 *34
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- AP ICATION FOR EXIT HARDWARE:
with comply with such provisions OI this permit shall be TRAILER USE GEOLOGY INSPECTION E] No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 1�
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. }/� `- �� —/ iJ �`•�
SPACES PARKING REQ'D PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date - DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OFNO. OF INSPE CTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL -
PRESENT USE OF BUILDING
Lic.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
License Law for the following reason (Section 7031.5, Busi-
ness
usi ness and Professions Code): NO. PARKING
SPACES PROVIDED r'•�Y.�. — - '�
DI, as owner of the property, will do the work and the
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.Q. �.Fi)
Lender's Name ';' `- -
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
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 , 7
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE la_ , 7
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date