HomeMy Public PortalAbout9849 FLAHERTY ST_Miscellaneous__ eP'a'ORKF.RS'COMPENSATION DECLARATION M ISCELLANEOUS APPLICATION
' CE 875
1 hereby affirm` CE 875 (11-84)that I have a certificate of consent to self COUNTY OF LOS ANGELES . BUILDING AND SAFETY DIVISION
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insure,-or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.). '
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS
FlCertified copy Is hereby furnished. ABUILDING
DDRESS T LOCALITY
5 `
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST. G
Date Applicant NEAREST .gyp DISTRICT NO G UP TYPE PR-
C SED BY
CROSS ST. ✓�� -/�v /2 CONST.1
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
J V
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
_ No, (CIRCLE) STATE MAJOR SEC ND LOCAL
NO. OF BLDGS. ^)'
(This section need not be completed if the work involved TRACT 3 NOW ON LOT Q` USE ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE OF
SIZE OF LOT dK/3 -F EXISTING BLDG. d
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 y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ` o
ADDRESSI.—
Date Applicant
T E L. (Rif ^� LLI
NOTICE TO APPLICANT: If, after making this Certificate of CITY ,0�/ (z T No. f L 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 USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
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. S Lvl r76il Ci t CLI PARKING
SPACES REQ'D PROVIDED
License Number Lic. Class I S�
T G�jQ� _ LIMITED TIME USE
Contractor Date r DATE DATE
FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S GNATU7
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 =g O V 0 Z
J
I hereby affirm that I am exempt from the Contractor's LL .
License Law for the following reason (Section 7031.5, Busi- # • o • •
ness and Professions Code): NO. PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the ° • • Q
structure is not intended or offered'for sale (Section
7044,Business and Professions Code). s,e &0)565
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING . ;I
Q 8 7
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 8 0 3.8 A
issued(Sec. 3097,Civ.C.). .
Lender's Name #.°I e,e,e 3 0
PROPOSED MAX. OCC. ,
Lender's Address ;I • o $�•5
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 C I o:o 10 8,0.5 0 60
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned proerty for inspection purposes., '.I, Q•0 1 t'8 7 �
-SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Date