HomeMy Public PortalAbout9903 HOWLAND DR_Miscellaneous__ WORKERS'COM PENSATI ON DECLARATION CE
MISCELLANEOUS APPLICATION {I
CE 8]8 111-84) LJ
I hereby affirm that i have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
"It,
It, nr a certificate of Workers'Compensation Insurance,or
a cer Ifled copy thereof(Sec. 3800,Lab.Q.
Policy`No Company FOR APPLICANT TO FILL IN BU IN.
ADDS S5 S
Certified copy is hereby Furnished. BUILDING
AODR E55 �O� /J/V 11) LOCALITY
❑ Certified copy Is filed with the county budding inspection LOCALITYNEAREST
department. *C/y/ L 4 C/ 7- CROSS ST.
DatC Applicant NEAREST /l i,J,� DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST. /�,. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
,COMPENSATION INSURANCE vESCRIPTION
LOT NO. BLOCK MAP I,1o.WA
NO, (C,--L.) STATE MAJOR SECOND LOCAL
(This SCCIIOn need not be completed If the work involved TRACT - NO. OF BLOCS.
NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE of
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this c D-
permit is issued, I shall not employ any person in any manner OWNER F Leo oa) �b L • 1/Z�d SI
so as to become subject to the Workers' Compensation Laws. AD DRE \J ` UPANCY GROUPMAIL55 77d /V, Sw, OCC4 op-
U
Date Applicant I„
TEL.
NOTICE TO APPLICANT: If. after making this Certificate of CITYT�/r/,Lc / T No. 2,r7- `/" OCCUPANT LOAD ti
Exemption, z
p you should become subject , the Workers- APPLICATION 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
deemed revoked. ❑ ❑ NO Spec, KnoWl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION g Panic Devices
1 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 IC ,A1 /IPp /I
effect. LTV Oa/+1 /t�� I -to - A Ax-- PARKING REO'D � —DIVIDED SPACES
License Number Lic. Class PF.t/17 r T _/,47�CE1/ UvT LIMITED TIME USE
Contractor Date DATc
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineerSIZE OF NO. OF wsPECTOR•s
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG, aa-77 -S6j STORIES L SIGNATURE
iness t Reg.No. Date PRESENT USE OF BUILDING and Professions Code).
Lic.or Reg. r[,6S _.
/� C�C L% FI. N AL APPROVAL
_ /
. . -_....
HOME OWNER-BUILDER DECLARATION NO. OF EXISTINGBUILDINGS
ON LOT AND USE ACCT
.T
I hereby affirm that I am exempt from the Contractor's _ 5�
License Law for the following reason (Section 7031.5, Busi- 3307 80.
ness and Professions Code): NO. PARKING
ITEMS.,
r `` \\r•\.�,
`
I, as owner of the property, will do the work and the SPACES PROVIDED �\ \, ITEMS.
structure is not intended or offered for sale (Section -"� � .�- , T(ITQLS o a�s0--+50
7044,Business and Professions Code). '
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING , _>`'\: ' CASH
I hereby affirm that there is a construction lending agency =may.'\,- .T_ \ -,;L. x�\ CHANGE; 'N
for
for the performance of the work for which this permit is _ N Y �1 '
issued(Sec. 3097,Civ.C.). -
Lender's Name �, \ r± ^,• �.i;\� ,`\ .` c ' x.
PROPOSED MAX. OCC. ` C`\ 1 n 00 '`.ib/2089
Lender's Address \ -�;,^ 27�c1. 1 •,j }�1;[11•
I certify that I have read this application and state that the - PERMIT Fee Q t - - t - 'v-
above information is correct I agree to comply with all County ISSUANCE Fee '7J
ordinances and State laws relating to buildingconstruction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon hove-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE• „ c \ •
Signature of Permittee Date