HomeMy Public PortalAbout10624 FREER ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 4) MISCELLANEOUS APPLICATION
CE 875(11-8
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS l7 7 J
Certified copy is hereby furnished. BUILDING FipEc p <� LOCALITY
ADDRESS /� J
Certified copy is filed with the county building inspection LOCALITY • /� j NEAREST
department. TE/�I P L C 1/ CROSS ST.
Date Applicant NEAREST //.../` r' �/� DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST, h!" 1110AJ ( 6 CONST
�{ _ ,, f Y
CERTIFICATE OF EXEMPTION FROM WORKERS' DESCRIPTION LOT/No. g��✓S a > � MAP HIGHWAY
COMPENSATION INSURANCE
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT Z/ NOW ON LOT USE ZONE 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. l o
permit is issued, I shall not employ any person in any manner OWNER
A4EN
so as:to become subject to the Workers' Compensation Laws. MAIL �� G OCCUPANCY GROUP a
ADDRESS o6 `,C S Ez I—'
Date Applicant il L'i
NOTICE TO APPLICANT: If, after making this Certificate of cITYr�/'�faL� G/T NOL S/�d'- � tf-4S-70 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. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E]
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 andQ
effect. PARKING REQ'D D PROVIDED D
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date 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 INSPECTOR'S
acting in my professional capacity (Section 7051, Bus EXISTING BLDG. G sroRlEs I SIGNATURE
inessand Professions Code). FINAL. APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING
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 { -
structure is not intended or offered for sale (Section
7044,Business and Professions Code). ,1-1 _ LF ® OSI
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING - -
I hereby affirm that there is a construction lending agencyfor the performance of the work for which this permit is 4NANGE
issued(Sec. 3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address 1 'ij1 -1 1 i_i; %;''`s ,'
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 - a'd -' i Aril
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned propertyforinspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
• nature of Permittee Date