HomeMy Public PortalAbout5664 LOMA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 I� �� �I p�LL=A v II ®U APPLICATION
I here'oy`affirm that I have a�,certificate of consent to self M
CE 875(11-84)
insure or a cei'tificate•of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING /
ADDRESS J���7CJ 77�tiJ
Certified copy is hereby furnished. ADDRESS SL' / � LOCAL4,TY
EJCertified copy is filed with the county building inspection LOCALITY NEAREST "
department. CROSS ST.
Date Applicant NEAREST ! DISTRICT NO. GROUP TYPE '� CESSED BY
CROSS ST. > I/ D O �s CONST."'
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o
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
slzE of Lor EXISTING BLDG.
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 OWNERd �( /yL 6R � 'R,. ='
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
oMAIL
ADDRESSJ� o Lo^A 44c-
Date
Applicant fJ L�Li
NOTICE TO APPLICANT: If, after making this Certificate of CITY �t_' Lj7 NOL 2A,— c (1) 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 oI�this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. El
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that'I am licensed under provisions of Chapter pG SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- O O NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. vPARKING REQ'D / I PROVIDED
SPACES
License Number Lia Class
-yg •6 LIMITED TIME USE
Contractor Date `� 7d DATE DATE
FROM: TO:
I am exempt from the licensing requirements as I am a ? 71-
licensed architect or a registered professional engmee SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE
iness and Professions Code).
� •„/
PRESENT USE OF B DING FINAL APPROVAL
V' J
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS W-
ON LOT AND USE UII s °
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness
usi ness and Professions Code): NO. PARKING ••-
SPACES PROVIDED I # �� _
1/0 I, as owner of the property, will do the work and the
moi• a�
structure is not intended or offered for sale (Section i ML 273,
7044,Business and Professions Code).
L .;
PROPOSED USE OF UILDING �• L •'••�•"-•'
CONSTRUCTION LENDING AGENCY '-'
. •I___I
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name ;) I's3 ` ; ='
PROPOSED MAX. OCC.
Lender's Address `' = 1 ?1
PERMIT FEE �C! i W F •
I certify that I have read this application and state that the G
above information is correct.I agree to comply with all County ISSUANCE FEE D
ordinances and State laws relating to building construction,
and he y authorize representatives of this County to enter TOTAL FEE
upon i above mentioned property ins ction purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee ate