HomeMy Public PortalAbout5743 LOMA AVE_Miscellaneous__ WORKERS'^COMPENSATION DECLARATION 76M444 I�� SC �I )I n p I1-'®UL� L�
CE 875 (11-84) M lL LLQ u�l LCC
I hereby 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.). C —7 p
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS V / r t+{i
Certified copy is hereby furnished. ADDRESS
7'y{^� 64
ADDRESS � / (J Pt' fQ LOCALITY
D Certified copy is filed with the county building inspection LOCALITY 1 /� L..
EST
department. 7L� C� ST. (A /�
Date Applicant NEAREST 4CT N GFFF(((��� TYPE PROLES D BY
CROSS ST. ` CON
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK HIGHWAY
(CIRCLE) STATE MAJOR SE CON LOCAL
NO. OF BLDGS.
(This Section need not be completed if the work involved TRACT NOW ON LOT NE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. / d
I certify that in the performance of the work for which this
permit is issued, I shall not emp y any perso in an
mmanner OWNER ` �1 0
so as to ecoe subject to the rkers' 6�e
on Laws. OCCUPANCY GROUP f M
MAIL p
Date t JApplican ADDRESS U
TEL' OCCUPANT LOAD n
NOTIC' TO APPLICANT: IQthabor
makin this Certificate of CITY No.
Exemption, you should bsubject to the Workers' APPLICATION FOR EXIT HARDWARE: _
Compensation provisions of Code, you must forth-
with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
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 �--
effect. T,YI S ^ SGL- Poo w PARKING (I'�I
SPACES REO�D D PROVIDED I�—J
License'Number Lic. Class c5! LIMITED TIME USE
Contractor Date DATE DATE
0 I am exempt from the licensing requirements as I am a FROM. TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSP CTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE
inessandProfessionsCode). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
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 9 3 8 7 A
structure is not intended or offered for sale (Section
7044,Business and Professions Code). # O O O o 30,
PROPOSED USE OF BUILDING • �
CONSTRUCTION LENDING AGENCY ( -' 6 g a 5 p
I hereby affirm that there is a construction lending agency
for the performance' of the work for which this permit is o o o 8 0.5 0 50'
issued(Sec. 3097,Civ.C.).
Lender's Name Q[) 4 "'88
PROPOSED MAX, C.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree.to comply with all County ISSUANCE FEE
ordi la es and State laws relating to building construction,
and h r by author' presentatives of this County to enter TOTAL FEE
upon b we- nti ed property for inspectio purp ses.
L. l3 p_j SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee /Date(1 Q