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Home My Public Portal About9684 LIVE OAK AVE_Miscellaneous__ CORKERS'COIvYPENSATION DECLARATION 76M444 p p ��p'�®�� APPLICATION��®p' CE 875(11-84). gyp I d N Insure, o affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING 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 p DD Certified copy is hereby furnished. BUILDING ARESS O ��ADDRESS LOCALITY �. ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST 0ISTRI T NQQ�� GROUP TYPE P - CERTIFICATE BY CROSS ST. ' /1CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL U COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP .1cH AY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF ///� SIZE OF LOT EXISTING BLDG. p / I certify that in the performance of the work for which this „ Q permit is issued, I shall not employ any person in any manner OWNER =� so as to become subject to the Workers' Compensation Laws. . MAIL OCCUPANCY GROUP / Q ADDRESS Date Applicant L0 T. NOTICE TO APPLICANT: If, after making this Certificate of CIT Nol. _ OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLI ATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT E] (LIST ITEMS BELOW NO. OF EXITS ness and Professions Code, and my license is in full force and effect. . , PARKING { �^ SPACES REQ'D D PROVIDEDJef D License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a PROM. 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 SIGNATURE iness and Professions Code). FINAL APPROVAL n Lic.or Reg.No. Date PRESENT USE OF BUILDING +- HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 4e) ON LOT AND USE Ar-r'" J1 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi -i ness and Professions Code): NO. PARKING SPACES PROVIDED — - a;••, I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044,Business and Professions Code). ;i-[ HLL ; = ® 5510 PROPOSED USE OF BUILDING •i i`� "i Ci CONSTRUCTION LENDING AGENCY r'.• tE K i •t;_• '•_1 I hereby affirm that there is a construction lending agency3^: f;j� �lWll for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Tt-I Ei j... .Lender's Address a.i,. L'"`I '' `'' PERMIT FEE �• '�1'�'-Is Ainforio ead this a plication and state that the �— orr .I ag ee to comply with all County ISSUANCE FEElaw rela ng to building construction, resent rves of this ounty to enter TOTAL FEEed prop ty for inspe t n urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Dae VI