HomeMy Public PortalAbout5761 LOMA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) I SC E L LA N E®U S APPLICATION
CE 875
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.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS 7 A 0 81 /;'_ � r
r /� ADDRESS � 7 J !✓/{iC Y'ry— L—
Certified copy is hereby furnished. BUILDING
DDRESS �7/ �{� LOCALITY C /
EhF�k _P1
0 Certified copy is filed with the county building inspection LOCALITY r NEAREST r/ llV//�,
department. L CROSS ST. A�5
Date Applicant NEAREST j/ DISTRICT NO. G UP TYPE P�rCESSEDY
CROSS ST. z CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 445-
J
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOC
NO. OF BLDGS.
(This SOCtIOn 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
d
I certify that in the performance, SIZE OF LOT EXISTING BLDG.
of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER y
so as to become subject to the Workers' Compensation La s. MAIL OCCUPANCY GROUP o
1 /l ADDRESS
Date Applicant C t„
TEL. OCCUPANT LOAD
NOTI*, ,O APPLICANT: If, after making this Certificate of CITY No. C/3
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 or this permit shall be TRAILER USEGEOLOGY 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- WO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. ` PARKING
SPACES REQ'D D PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPE CTO RAS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S NATURE
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date �—
PRESENT USE OF BUILDING I l/
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE 7�
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 P 1 2-61 A
r7 I, as owner of the property, will do the work and the SPACES PROVIDED # 0 0.0 0.3 0
1180 structure is not intended or offered for sale (Section
7044,Business and Professions Code). I o o 8 0. 5.0
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency 0 ° ° 8 0 5 0
for the performance of the work for which this permit is .1 2 0 6 8 8
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
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
ordinances and State laws relating to`building construction,
and hereby authorize representatives of this County to enter TOTAL FEE Q f
upo 11e above-mention rope;4y for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date