HomeMy Public PortalAbout10743 FREER ST_Miscellaneous__ WORK-F RS'COMPENSATION DECLARATION CE 875(11-84) M ISCELLANEOUS APPLICATION
Irebaffirm 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 v
MCertified copy is hereby furnished. BUILDESSING
ADDR _ �C LOCALITY
Certified copy is filed with the county building inspection LOCALITY
NEAREST
department. CR OSS
ST.
Date Applicant NEAREST DIS RIGT GROUP TYPE CES BY
CROSS ST. CONST,
CERTIFICATE OF EXEMPTION FROM WORKERS" LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NOOF BLDGS. NO. (CIRCLE) STATE MAJOR ECOND LOCAL
(This section need not be completed if the work involved TRACT NO.W ON LOT IJ¢E ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) h us E OF
SIZE OF LOT EXISTING BLDG. 7/s��Jr�/Vjs
/v V �� 9•-
I certify that in the performance of the work for which this CD
permit is issued, I shall not employ any person in any manner OWNER s�
so as to become subject to the Workers' Compensation Laws. MAIL j OCCUPANCY GROUP
ADDRESS
Date Applicant w
TEL.
OCCUPANT LOAD a
NOTICE TO APPLICANT: If, after making this Certificate of CITY � No. � Cn
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: _
with comply with such provisions or this permit shall be
deemed revoked. TRAILER USE EJ GEOLOGY INSPECTION p No Spec. Knowl.
CTieIC4(.1 Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (L'IST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code, and my license is in full force and j�
.effect. L t�_r , Q, PARKING
- SPACES REp,D D PROVIDED D
License Number Lie. Class 10
LIMITED TIME USE
Contractor Date 41ke /l6�/ �tg , , `�� DATE DATE
❑ 1 am exempt from the licensing requirements as I am aul •$ — ,� o ro
licensed architect or a registered professional engineer SIZE OF //�// NO. OF FROM: TO: INS CTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. ! STORIES SIGNATURE
iness and Professions Code). ,
PRESENT USE OF BUILDING
FINAL APPROVAL
Lie.or Reg.No. Date _ ,%
/
�i
HOME OWNER-BUILDER DECLARATION NO. OF Ex STING BUILDINGS rq
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ar
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO, PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the 3307 ;11n
structure is not intended or offered for sale (Section Ii
7044,Business and Professions Code). I
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING �_� TAL 5
TO8O m 0
TOTAL e
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CHECK ;,_,lam
` 0 1
issued(Sec. 3097,Civ. C.). k1N 1NGE
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE , 0 1 1000-0001 Il 2,/8.9
above information is correct.I agree to comply with all County ISSUANCE FEE so 6532 { 11I��^
ordinances and State laws relating to building construction, '
and hereby author' a re esentatives of this County a ter TOTAL FEE
up n t bove-me do prop t for ins ection pu os
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ature of Permittee Da