HomeMy Public PortalAbout10044 GREEN ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C AT I O N
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I hereby affirm that I have a certificate of consent tself CE 875 (11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING t LOCALITY
ADDRESS (�{�
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO. I GROUP TYPE I PROCESSED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MPP HIGHWAY NO. CIRCLE
STATE MAJOR SECOND LOCAL
_ (
NO. OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
a
SIZE OF LOT EXISTING BLDG. CD
I certify that in the performance of the work for which this LU
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. MAIOCCUPANCY GROUP "-
L
ADDRESS "\ -j J � a
` Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. OCCUPANT LOAD Cn
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such pIOvlslons Or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. w
deemed revoked. Panic Devices
El
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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. PARKING REgD I I PROVIDED I I
SPACES IIJ LL-- J
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF INSPSIGN TORATURE
E
GN
acting in my professional capacity (Section 7051, Bus- EXIS'OF NO.17ING BLDG. STORIES
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
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 7 Y
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING a.'I
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). ?
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
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
ordinances and State laws relating to building construction,
and hereby auxhorize representatives of this County to enter TOTAL FEE
upon the ab fie-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitted' Date