HomeMy Public PortalAbout4856 HELEO AVE_Miscellaneous__ r� ERS'COMPENSATION DECLARATION ` 76M444
05, ; ► CE 875 (11-84) MISCELLANEOUS APPLICATION
I reL_ that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,ure; orr affum 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 J
Certified copy is hereby furnished. BUILDING
SS 5 LOCALITY
ADDRE01 Z
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. f CROSS ST.
Date Applicant NEAREST DISCT NO G APIYP- PROC SSED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L Il
COMPENSATION INSURANCE DESCRIPTION LOT NO. C BLOCK a MAP NI HW AV
' No. (CIRCLE) STATE MAJOR SE CON LOCAL
_ NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT. U 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 8d _ "�5�� EXISTING BLDG. o
permit is issued, I shall not employ any person in any manner OWNERS <" 0 ='
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP _ o
ADDRESSS� •� U
Date Applicant we
L CL-
NOTICE TO APPLICANT: If, after making this Certificate of -IT- 6M,2/,f f NO. �f� -icy �'��f OCCUPANT LOAD
Exemption, •you should become subject to the Workers' APPL ATION 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 Ievoked.
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. fs SPACES PARKING REQ'D PROVIDED
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
e
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE .' 9 O g(1 5 fl
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. PARKING7,
p 25 .=88
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).
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING -�
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
I certify that I have read this application and state that the PERMIT FEE
n
above information is correct.I agree to comply with all County ISSUANCE FEE 0
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned operty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
7®t0
Signa r of Permittee Da