HomeMy Public PortalAbout9816 FLAHERTY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (11-84) MISCELLANEOUS APPLICATION
I hereby affirm that 1 have a certificate of6n hent to c ,self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance;or •
a certified copy the 3800,Lab.CO. ;
Policy No pany � � FOR APPLICANT TO FILL IN BUILDING
• ADDRESS
Certified copy is hereby furnished. BUILDING
ADDRSS / LOCALITY
EIC/
a��
is filed with the county building inspectionLOCALITYNEARESTCROSS ST.Applicant� NEAREST DISTRICT NO. M��NEST.
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CROSS ST. },'Q -
CERTIFICATEOF EXEMPTION FROM WORKERS' LEGAL !/
COMPENSATION INSURANCE DESCRIPTION FLOT NO. BLOCK MAP —, HIGHWAY STATE MAJOR SECOND LOCAL
NO. OF BLOGS. N0.��3 C (CIRCLE)
(This Section need not be completed if the work involved TRACT NOW ON LOT 3,ONE: SPECIAL CONDITIONS
by the permit is for one hundred'dollars ($100) or less.) USE OF
I certify that in the performance,of the work for which this SIZE OF LOT EXISTING BLDG.
permit is issued, I shall not employ any person in any manner OWNER )04 s�
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP
0
ADDRESS I--
Date Applicant W
TEL' OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of clry No. — 01
Exemption, you should become subject to the Workers' z
EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR _
with comply with such provisions oI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. ❑ E] No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
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 r
effect. _ —/CJ PARKING RSQ'D E� PROVIDED
SPACES J
License Number 1�LLic. Class-� �--
//����,, p1cc •���� LIMITED TIME USE
ContractoiL ,(' 5 Date -27q Z DATE DATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF FROM: TO: INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL -_ __V1
PRESENT USE OF BUILDING
Lic.or Reg.No. Date 15
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 and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the sPAces'PROVIDED F n
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 ='ttaw 0
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). _ '
Lender's Name I
_
PROPOSED MAX. OCC. „•'.i ,iisf_ 'fes
• 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 _'I_'h)•-ti_l:�i ,Ir, 1I+
ordinances and State laws relating to building construction,
and hereby aut r e representatives of this County to enter TOTAL FEE AM :� '
U he over ned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig tui .of Permittee Date