HomeMy Public PortalAbout5402 LOMA AVE_Miscellaneous__ WOIcKERS'COMPENSATION DECLARATION 76M444
f . CE 875 (2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure, or a certificate ot'Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab C.)
Policy No Company FOR APPLICANT TO FILL IN BUILDING .1Vt
ADDRESS
F1Certified copy is hereby furnished BUILDING -V LOCALITY L U
ADDRESS
ElCertified copy is filed with the county building inspection NEAREST r
department LOCALITY 7,g�epv
C � CROSS ST
Date Applicant NEAREST DISTRICT,NO G�l OUP TYPE PROC D BY
CROSS ST O L� S ff Z CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I J
COMPENSATION INSURANCE DESCRIPTION LOTYNO BLOCK MAP HIGHWAY }'
No. (CIRCLE) STATE MAJOR SEGO LOCAL tZ
(This section need not be com feted if the work involved , NO OF BLDGS ` USE ONE S ECIAL CONDITIONS. O
P TRACT NOW ON LOT
by the permit is for one hundred ,dollars ($100) or less.) USE OF
' SIZE OF LOT EXISTING BLDG tY
I certify that in the performance of the work for which this O
permit is issued, I shall not employ any person in any manner OWNER, I-
so as'to become subject to the Workers' Compensation'Laws. L® OCCUPANCY GROUP W
MAIL
ADDRESS ��O C�7/1 R- - d
Date Applicant N
NOTICE TO APPLICANT If, after making this Certificate;of CITY (j��-' ' NO. OCCUPANT LOAD Z
Exemption, you should become subject to 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 USEGEOLOGY INSPECTIONEl
deemed revoked ❑ ❑ No Spec. Knowl. Q
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION� .
Panic Devices
I hereby affirm that i am licensed under provisions of Chapter SAFETY PERMIT ❑, (LIST 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 andPARKING.
effect 29' ,02, SPACES REO'D PROVIDED,
License Number Lic Class-'
OK
LIMITED TIME USE
Contractor Date DATE DATE
❑ > - FROM TO
I am exempt from the licensing requirements as I am a
licensed architect or a registered' professional engineer SIZE OF / No OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG O O STORIES "IGNATURE
iness and Professions Code) FINAL APPROVAL
l PRESENT USE OF BUILDING
Lic.or Reg No Date �C!
HOME OWNER-BUILDER DECLARATION ON LO
O EXISTING BUILDINGS
OT AND USE -
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. PARKING
AV
SPACES PROVIDED
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) �4 � 3 3 A
• PROPOSED USE OF BUILDING ,
CONSTRUCTION LENDING AGENCY # 0 0 0 0 3 Q
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is -,o 8 Q 5 0
issued (Sec.,3097,Civ C)
Lender's Name PROPOSED MAX OCC o o e 8 a 5,0 5
Lender's Address PERMIT FEE
022 8;a 86
I certify that I have read this application and state that the a
above information is correct I agree to comply with all County ISSUANCE FEE10 C9 n
ordinances and State laws relating to building construction, TOTAL FEE //,, "R
and hereby authorize representatives of this County to enter Vl v
jUZ6�entioned{ properttyfor inspecctt/ionpp/u_rposes SEE REVERSE FOR EXPLANATORY LANGUAGE.�A r/� Yl 1I LY- x 1^Off.(/
Signature of Perindlee Date