HomeMy Public PortalAbout6236 LOMA AVE_Miscellaneous__ WO gKERS'COMPENSATION DECLARATION 76M444C ` f� l SC L LA N IEO U S APPLICATION
E 875 (11-84)
I affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
ins ee,, o or a certificate of Workers'Compensation Insurance,
e,or
a certified-copy thereof(See. 3800,Lab C.).
Policy-No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. N-
54 Al- Le2i�2k
�L E
ADDRESS LOCALITY
0 Certified copy is filed with the county building inspection LOCALITY NEAREST ,
department. CROSS ST
Date Applicant NEAREST DI�STR ICT NO. G OUP TYPE inSE
Y
CROSS ST. AOI (_ V 2 CONST 1
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �I Jl J t_J�I/
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SE OND 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.) D O USE OF
SIZE OF LOT EXISTING BLDG. r 7"
I certify that in the performance of the work for which this °-
permit is issued, I shall not employ any person in any manner OWNER o
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
ADDRESS
Date Applicant ui
TEn
NOTICE TO APPLICANT• If, after making this Certificate of CITY NO.
OCCUPANT LOAD �s
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 or 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
9 (commencing with Section 7000) of Division 3 of the Busi E] (LIST ITEMS BELOW) NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. entLegaw dV NV 2/4-W(I KING
CES REQ'D O PROVIDED D
License Number Lic Class � � 01 LIMITED TIME USE
Contractor Date DATE DATE
'� FROM
D I am exempt from the licensing requirements as I am a U /11 D%!� TO
licensed architect or a registered professional engineer slzE of NO OF INSPECTOR'S
acting m my professional capacity (Section 7051, Bus- EXISTING BLDG /�/ I STORIES / IGNAT E /
mess and Professions Code). I FINAL APPROVAL f/
PRESENT USE OF BUILDINGI AJ A
Lic or Reg No Date ,
UV
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS ' e4
ON LOT AND USE r 3107 Z93.1it+
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- 1 ITEMS
EMS
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the
SPACES PROVIDED 4- TOTAL 93 . 00
structure is not intended or offered for sale (Section CHECK 91.;.00
7044,Business and Professions Code). CHANGE
ii_��[' r
PROPOSED USE OF BUILDING `•���VE °EIfl
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 00130-0001
� � _ I
issued(Sec 3097,Civ.Q. I 0l � (] 01 7/19/011-1
rjl1
Lender's Name �� i AN 7:5*
Lender's Address
PERMIT FEE . PROPOSED MAX. OCC.
06)
14
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 3, 00
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter T ;L FEE V3 , O
upon the above-men'tgned prope y for inspection purposes.
p •SEE REVERSE FOR EXPLANATORY LANGUAGE
S a�of Permittee Date