HomeMy Public PortalAbout10847 FREER ST_Miscellaneous__ WORKERSIV(k.MPENSATIONDECLARATION 76M444
CE 675 (11-84) MISCELLANEOUS APPLICATION -
I hereby a cert 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(See. 3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING I [i
! Q 8 7 y
ADDRESS �1 / / � ST' LOCALITY
FCertified copy is filed with the county building inspection LOCALITY 7L^�"M NEAREST
department. / v /nPLC �'!�- CROSS ST.
Date Applicant NEAREST /� }. DISTRICT NO. G UP TYPE �j OC SSED BY
CROSS ST. S/`�N/ A ^� CONST.;
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP ��J HIGHWAY
NO/W_ // (CIRCLE) STATE MAJOR SECOND LOCAL
/� NO. OF LOGS.
(This section need not be completed if the work involved TRACT b (J NOW ONBLOTa USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT .�X-4/ 3 EXISTING BLDG• ��
I certify that in the performance of the work for which this
0
permit is issued, I shall not employ any person in any manner OWNER M f �AIn S OGLE- y
so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP �
ADDRESS /D of C'. FR6--'2 c::)
Date Applicant c.5
TEL. LV
NOTICE TO APPLICANT: If, after making this Certificate of clrY f'C JOZ j /f- No. �,Z� y 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
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. , REq'D D PROVIDED D
License Number Lic. Class SPA SPACES
PARKING
8 E D US C �'X V S� FA/jJ LIMITED TIME USE
Contractor Date DATE DATE
EJI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF I TOR
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIESC1 SIGN
i
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING
CSi o -nJ C 3-1741
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's � USC- /' 2 (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). i I"(' f a O-0
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING i�;_;i`•: - !!
I hereby affirm that there is a construction lending agency +
for the performance of the work for which this permit is '=Hf) °=4=
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC. '-':I.i�• �l viii�� i f i_ -
Lender's Address ''''`- - =` 1 • • -
PERMIT FEE i�� [; •1 ? f'
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 / d�
ordinances and State laws relating to building construction,
and by authorize representatives of this County to enter TOTAL FEE 3
u n th above-m oneproperty for inspection purposes.
q^Q� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature cf Permittee Date /