HomeMy Public PortalAbout4903 HELEO AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION a
CE 875(11-84) MISCELLANEOUS
ISCELLANEOJS A P P L p C A T I O
I hereby affirm that 1 have a certificate ofconsent tself 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 FI LL IN ABUILDING
DDRESS
❑ Certified copy is hereby furnished. BUILDING / y
ADDRESS " �� c/..CD AVC'*
LOCALITYKy
/o'l
0 Certified copy is filed with the county building inspection LOCALITY -r NEAREST
department. �/N `� Cl CR OSS
ST.
Date Applicant NEAREST ,I ' DISTRICT NO. GROUP TYPE P CESSED BY
CROSS ST. Q�(,/ �Q, V� , M CONST. ••
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL %
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(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 r
SIZE OF LOT5,3 x ✓ EXISTING BLDG. J
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 =-.'>
so as to become subject to the Workers' Compensation Laws. IAJA"MAIL ", n u t OCCUPANCY GROUP 3 0
ADDRESS � �3 L��� A y 6 1'
Date Applicant LVI
NOTICE TO APPLICANT: If, after making this Certificate of -11__)24 0,2L6 �� TN-L'R -��6.,�q� -7 OCCUPANT LOAD O_
Exemption, you should become subject to the Workers' APP KATION 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. E
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 and t /��
effect. �� V�C n A I PARKING REQ'D PROVIDED
SPACES
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE` DATE
FI 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. �D 7� f STORIES SIG TORE
iness and Professions Code). '/
Lic.or Reg.No. Date PRESENT USE OF BUILDING WE �bG�I FINAL APPROVAL
K i6 aRA6C -
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 17�7lAQ/�
�
I hereby affirm that I am exempt from the Contractor's ON LOT AND USE 7V R�e ROWS v
License Law for the following reason (Section 7031.5, Busi-
ness
usi ness and Professions Code): No. PwRKING --•-• �y-I' ,t.-
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).
' PROPOSED USE OF BUILDING !'?�4'•_; •� ,�,: '
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency i�rRiczL ,_:
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 D, 91•ifr - L-'R•':3z?'Ic'i"Q
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 authorize representatives of this County to enter TOTAL FEE
upon the above-men one operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
will
Signature of Permittee Date