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HomeMy Public PortalAbout5730 LOMA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) M I SC E L LA N E®U S APPLICATION CE 875 I her.-bor a certificate 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 ADDRESS Certified copy is hereby furnished. BUILDING 57�?O �O LOCALITYZ' ADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. (, qS 7Lf-cry Date Applicant NEAREST DISTRICT NO. GROUP TYPE P CESSED BY CROSS ST. - /� CONST. 6 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLD S. (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 I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. O permit is issued, I shall not employ any person in any manner OWNER =' so as to become subject to the Workers' Compensation,Laws. MAIL ren 6 6 OCCUPANCY GROUP o ADDRESS 36 &7A hY{�/ � ~ Date Applicant TE NOTICE TO APPLICANT: If, after making this Certificate of CITY Q- NOLOCCUPANT LOAD Exemption, you should become subject to the Workers' APPLIC TION 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 INSPECTIONE] No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION P___� Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter q SAFETY PERMIT LIST ITEMS BELOW 9 (commencing with Section 7000) of Division 3 of the BUST NO. OF EXITS ness and Professions Code,and my license is in full force ander 4{{�{ effect. L%� �e�=Q PARKING RE VPF?OYIDED ,j[I pl��E y/ SPACES License Number Lic. Class !�(! LIMITED TIMEl-S Contractor Date DATE OA242_ 0 ElI am exempt from the licensing requirements as I am a FROM: TO: CASH 94 .70 licensed architect or a registered professional engineer SIZE OF NO. OF CHANG INSPE oR s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES CHANGsIG uRE ,Q0 inessand Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING ' Lic.or Reg.No. Date _If 1101 i 1195 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 935R 7 t AN10:46 ON LOT 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 ❑ I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED uSE OF BUILDING 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 PROPOSED MAX. OCC. Lender's Address PERMIT FEE / 7 Lf I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE -273© ordinances and State laws relating to building construction, and ereby authorize representatives of this County to enter TOTAL FEE �/� 2 .-7Q U" he above mentioned erty for inspec ' n purposes. R S FOR EXPLANATORY LANGUAGE 7s Signature of ermee ate -/9- itt