HomeMy Public PortalAbout4933 FIESTA AVE_Miscellaneous__ 76M44
20-006 _ .
W,ORKE,RS; COMPENSATION-DECL•ARATION 20-0063DPW 12/90 -MISCE.LL:ANEOU A'T"ION
I�,hcreb} affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES t.�1D SAFETY DIVISION
ir:,ure;or'a cbrfiflcate'of W6fke'rs Compensati,on Insurance, or
a'certified copy there'of`(Sec'3800: Lab. C.)
Policy No. Company BUILDING ADDRESS ADFOR APPLICANT TO FILL IN BULL �!`] i�1:>
DRL ""1 ✓ S f••,
❑ Certified co Is hereby furnished. �f n
pY' Y VY� LOCALITY
❑ Certified copy is`filed with the county building inspection CITY n ZIP (� �.I
department. • ' t /i / fy I XO/ NEAREST
V CROSS ST. f�
Date Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT No. GROUP TYPE PROG ssED BY
.
.CERTIFICATE OF EXEMPTION FROM CONST.WORKERS' v `�
COMPENSATION INSURANCE TRACT�/��� BLOCK LOT NO. Q� MAP HIGHWAY Y
/ v NO. (CIRCLE) STATE:MAI I R SECOND LOCAL
(This section need'?lot be completed if the work involved ASSESSOR.MAP BOOK Q/"qO PAGE PARCEL USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) Ow �.
I certify that in the performance of the work .for, which this OWNER TEL NO. ' o�(
permit ' issued, ( shall"not. W any person in zany manner ADDRESS
so as to•bec.onie subject,to the Workers' Compensation Laws. 3 OCCUPANCY GROUP
Date- Applicant CITYZIP
U
NOTICE TO APPLICANT: If, after making this Ceftificate 7-x,.1 �--e G�� r14 If I OCCUPANT LOAD 6
of Exemption, you Should 'become subject to the Workers' AP (CATION FOR
Compensation•provisions'of the Labor Code,you must forthwith EXIT HARDWARE:
cornply with;.such provisions or this permit Shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑
revoked. 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) a
9(commencing with Section 7000)of Division 3 of the Business NO.OF EXITS
and Professions Code,and my license is in full force and effect. , j f
PARKING• REQ'D PROVIDED
License Number Lie. Class SPACES D
Contractor Date ell, LIMITED TIME USE
❑
- - DATE DATE I am exempt from the licensing requirements as 1 am a FROM: TO:
licensed architect or a registered professional engineer
acting In myprole SSlOtlal capacity (Section 7051;Business SIZE OF NO.OF INSPECTOR'S
EXISTING BLDG. STORIES SI
and Professions Code).
G UR
LIC. or Reg. No. Date PRESENT USE OF BUILDING FINAL:APPROVAL
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE 30
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 70315, Business and ACi.'Tos
Professions Code): - NO.PARKING -y,j�,tjye
-, —
SPACES PROVIDED
rIJ'1 ••-
❑ a,•�_;°;I_{1, as owner of the property. will do the work and the
structure is not intended or offered for sale(Section 7044. PROPOSED USE OF BUILDING .•, ITE(M
'e
Business and Professions Code). Ti-lTAL 242 70
CONSTRUCTION LENDING AGENCY I_ �{:{ y .`° 3i
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued �.E(AN(�E °rti-1
(SCC. 3097, CIV. Q.
PROPOSED MAX.OCC. -
Lender's Name APPLICANT(PAINT) TEL NO.
Lender's Address ADDRESS ^ ` b / 0000-0001 5 13,/9
1 certify that 1 have read this application and state that the 6357G7
/� a/�
�' i Arl ....
above information is correct. I agree to comply with all County PERMIT FEE ' 7
ordinances and State laws relating to building construction,and
hereby authorize representatives of this County to enter upon ISSUANCE FEE
the above-mentioned property for inspection purposes.
I J
TOTAL FEE 2—
✓ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date