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Home My Public Portal About10270 LIVE OAK AVE_Miscellaneous__ WORKEZS'COMPENSATION DECLARATION 76M444 CE 875(2-90) R� ISCELLANEOUS APPLICATION I`Fereby affirm triat I have a certificate of consent to self COUNTY OF,LOS ANGELES ING AND SAFETY DIVISION insure, or 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 7i1 J ADDRESS 0 Certified copy is hereby'furnished BU'LDING ,02 70 �� LOCALITY - ADDRESS - ❑ Certified copy is filed with-thecounty building-inspection NEAREST 01 department . LOCALITY � �� G��y �1 CROSS sT '-D 7ate Applicant NEAREST DIS CT O GR UP TYPE P D BY a CROSS ST. y0j.,� �� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 07 COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK. MAP - HIGHWAY 'I (CIRCLE) STATE MAJOR SECOND LOCAL _ •t NO .OF BLDGS NO (L section need not be completed if the work involved TRACT NOW ON LOT E PEC IAL CONDITIONS 10 _,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 or permit Is Issued, I shall 'not employ any person m any manner OWNER �` �� ` r L,/SOd✓' so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP U n ADDRESSLLJ L� - ` Date•'~' Applicant vCL Cn TEL' - NOTICE TO APPLICANT If, after making this Certificate of. CITY NO- 1fliFS 6SjjI OCCUPANT LOAD` " " Z Exemption, you—should become subject to the Workers' APPLICATION FOR EXIT HARDWARE c C0'pens_ation provisions of the Labor Code, you mu_st forth- ' With comply with such provisions' or this permit shall be TRAILER USEGEOLOGY INSPECTION deemed'xevoked. 0 _❑ , No Spec KnOWI. El LICENSED CONTRACTORS DECLARATION PCCUPANCY INSPECTION Panic Devices• ❑ I hereby affirm that I am'licensed under provisions of Chapter SAFETY PERMIT E] IST ITEMS BELOW) NO OF-EXITS ❑ 9 (commencing with Section-7000) of'Division 3 of the Busi- _ ness and Professions-Code, and my license is in full force and PARKING. effect '"« W L REq'D o PROVIDED - ' SPACES License Number Lic Class LIMITED TIME USE Contractor ' - - Date ` DATE DATE 1 ❑ ' - ' • FROM TO I am exempt from the licensing requirements'as I am a licensed architect or' a registered professional, engineer SIZE OF NO OF �. -INS Euro R'S acting' my pro fessio nal�capacrty (Section 7051', Bus- EXISTING BLDG � pao p�, STORIES �+T+i/FI .5P'tE mess and Professions Code) FINAL APPROVAL _ \ PRESENT USE OF BUILDING (,ic,or Reg No Date ' NO.,OF EXISTING BUILDINGS 1 HOME OWNER-BUILDER DECLARATION- ON LOT AND USE OP�s�Ot'�Ga D' 6 2,290,4A' I 'thereby affirm tliat I am exempt ,from the Contractor's License Law for the following reason (Section 7031 5, Busi- e o 3 0 __ness,a •Professions Code) NO. PARKING SPACES PROVIDED O IO ,u I; as,�oivner of the property, will do the work and the 2' i 6,2`5 0 structure is not intended or offered for sale (Section •e'e!6250U 67GJr0 7044;Business and Professions Code). _ PROPOSED USE OF BUILDING --:-'CONSTRUCTION LENDING AGENCY - - _ r` '0 2,0'9�-8 2 ' I he"r"eby affirm that there is a construction lending agency :,for=thc, performance of the work for which this permit Is issued'(Sec-"3097„Civ C) Lender's Name I _ PROPOSED MAX OCC dre Lender's�Adss PERMIT FEE I'certify,that I have read this application and state that the above mforrriation is correct I akree•to comply with all County ISSUANCE FEE - ordinances and State laws•relating to building construction, and hereby authorize'representatives ofIthis County to enter TOTAL FEE1 upon'the above- tioned property for' inspection purposes- SEE REVERSE FOR`XPLANATORY LANGUAGE Signature of Permittee - Dae