HomeMy Public PortalAbout5742 LOMA AVE_Miscellaneous__ \,,r(,R9KF7kS.COMPENS,ATIO DECLARATION �776M4Jr44�
CE 875 (11-84) MISCELLANEOUS APPLICATION
I hereby affirm that i have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(See. 3800,,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING '1
ADDRESS x
Certified Copy is hereby fUrnl$lled.' ADDRESS 5742 Loma Ave • I LOCALITY
A
Certified copy is filed with the county building inspection LOCALITY Temple City NEAREST
department. - _ CROSS ST.
Date - Applicant NEAREST C DISTRJ}..��T NO. GF�,UP TYPE / PROCESS BY
CROSS ST. South of Las Tunas '3/ Z CONST.'
CERTIFICATE OF EXEMPTION FROM'WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. 23 JEILOC. MAP HIGHWAY
NO., (CIRCLE) STATE MAJOR SE.CO ND OCAL
NO. OF BLDGS.
(This Section need not be completed if the work Involved, TRACT , 12977 NOW ON LOT US ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) q Q USE OF
SIZE OF LOT 51 - 31x178 8 EXISTING BLDG.res . d
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 Jac ul n R'. Comstock .
so as to become subject to the'Workers' Compensation Laws. MAIL , OCCUPANCY GROUP \' -' a
ADDRESS same as above.
Date Applicant
NOTICE TO APPLICANT: If; after making this Certificate.of CITY No. 286-5333 -` OCCUPANT LOAD
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions oI this permit .shall beTRAILER USE `GEOLOGY INSPECTION
deemed revoked. ❑ ❑ No Spec. KnovuL,
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION EJ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) a
9 (commencing with Section 7000) of Division 3 of the Busi- No, of EXITS
ness and Professions Code,and my license is in full force and, Installation of forced air heat
effect. - PARKING REQ'D D PROVIDED
central air condi 1011. ep arCe SPACES
License Number. Lie. Classlae�tted hot water 11I LIMITED TIME USE
Contractor Date laundry room to oiitside . Removed DATE DATE
I am exempt from the licensing requirements as I am a a.rtia wa l be ween kitchen. & TD:
licensed architect or a registered professional engineer install—" INSPECTOR'S
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIG/MATURE:
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDINGresidence .
Lie.or Reg.No. Date
Y
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BfIL eG idence & 1 double
ON LOT AND USE 11 ham- r 9 3 6 2 A
I hereby affirm that I am exempt from the Contractor's detached garage . # 0 o.o�s 3 0
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED double garage & drive ,, , �. I'' 8.Q-•5;0
I, as owner of the property, will do the work and the y
structure is not intended or offered for sale (Section way•
7044,Business and Professions Code). / ems. o 0 8 0
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING *ed" new Sin! Ba h //
I hereby affirm that there is a construction lending agency moved & replaced window:
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
I certify that I have lead thisapplication and state that the PERMIT FEE 80 . 50,
above information is correct.I agree to comply with all County ISSUANCE Fee
ordinances and State Iaws.relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
uft the above-mentioned roperty for inspection purposes.
i SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ature of Permittee �" Date