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Home My Public Portal About4930 FIESTA AVE_Miscellaneous__ WOIZKERS 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 insure icF a certificate of Workers Compensation Insurance e or a certified copy thereof(Sec 3800 Lab C) Policy No Company FOR APPLICANT TO FILL IN ADDRESS FICertified copy is hereby furnished BUILDINGr� ADDRESS LOCALITY6A4& A4 ❑ Certified copy is filed with the county building inspection LOCALITY �A NEAREST department I M I CROSS ST , Date Applicant NEAR.ST DISTRICT N GR P TYP PROLE ED BY CROSS ST / CO ST ' CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY RD (CIRCLE) STATE MAJOR SE CO LOCAL NO OF BLDGS (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) USE OF d I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG o permit is issued I shall not employ any person in any manner OWNER S 1 =_') so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP �� 0:t Date Applicant ADDRESS S m ub `` � LiJ TEL NOTICE TO APPLICANT If after making this Certificate of CITY NO Zg j—890(O OCCUPANT LOAD D_ 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 OI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked E] ❑ No Spec Know[ 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 �7 �� { YZrV L_ t enmonrioo PARKING REQ D PROVIDED License Number Lic Class SPACES LIMITED 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 INSPECTOR S acting in my professional capacity (Section 7051 Bus EXISTING BLDG STORIES /SIGNATURE mess and Professions Code) FINAL APPROVAL ✓7 PRESENT USE OF BUILDING lj 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 Contractors License Law for the following reason (Section 7031 5 Busi ness and Professions Code) NO PARKING ;2 6 2 5 7 A I as owner of the property will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section t `� 7044 Business and Professions Code) 805075 x • 8 0 5 0 75 CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ,ol 02'-87 1 hereby affirm that there is a construction lending agency 1 !^ _ 1ti� , ♦� , for the performance of the work for which this permit is issued(Sec 3097 Civ C) r Lender s Name PROPOSED MAX OCC Lender s Address I certify that I have read this application and state that the PERMIT FEE I 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 !� T the abov me ed prop y for inspection purposes 'Mon ) 11— Z r P.r7 SEE REVERSE FOR EXPLANATORY LANGUAGE nature o ermittee Date A 4�0 i'y.'•t -Ct�vP'TY �F - k IM ARCELES r ..- • � • • r •i✓ n4� 'B"# 1 - • - " P`s A T a i+'1 f l•oCil]t♦ r tract 2.0./ 9 Lot Ao. �5'� _ Lot Sise a ' ` =��L`E :�di�E/� •Zi FiT.E_ :itE � .2j �O Sq. Ft. O Pu1,ding Fermat Issue Date%a Final Late Df=c rept cn of wor} Sq. Ft. `L:_`: t` �Er-_• = Issue Date. ari�1 aF f Descrlptlon of work Sq. Ft. a Pulld:r,L Perzzt Issue Date Final Date Description of work seq. Pt. MOTE: The information given is taken from Building Permit Records. Un- less an Occupancy Inspectlon is requested, and the tee for this inspection is pard, nD investigation of the property will be wade by this Department . t ` Se1►er ftrrjt t' Issue,Dste y .4ksb t'Dr rectee tr sa}ern i s:rgft • Inspection Date w 1 Y4 , w � • �w , SIL i w 1 � t t t t -�yr, 4 +4 _ � 1 Y +.