HomeMy Public PortalAbout6267 LOMA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
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 FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING6267
L nJ.� (�F LOCALITY
ADDRESS (/I" •c.-
DCertified copy is filed with the county building inspection LOCALITYT �] NEAREST
department. /��PLE C .L CROSS ST.
Date ' Applicant NEAREST ���/^`�! DISTRICT NQ. OU TYPE P CES E BY
CROSS ST. CT11[r-—Al�V 5/lJ/�➢pV`// CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJO SECOND 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.) i usE of
SIZE OF LOT x�Q EXISTING BLDG. }'
I ceitify that in the performance of the woik for'which this o
permit is issued, I shall not employ any person in any manner OWNER Z_< �j��
so as to become subject to the Workers' Compensation Laws. MAILJ�/�/� OCCUPANCY GROUP o
Dat
I e Applicant ADDRESS � L-(/��/
6 A ��,
LI
NOTICE TO APPLICANT: If, after making this Certificate of CITY T�Nj10�� CI t}' NO. ,;IF -11 7 OCCUPANT LOAD a-
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 oI this permit shall be TRAILER USE ❑ GEOL GY INSPECTION ❑ No Spec. Knowl,
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETv PERMIT F] (LISr9TEMS 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 J_�/I y�QV�0 8fQ7WCVA7 I�IMS�l�—
PARKING
effect. REQ'D PROVIDED �_ I
I C SPACES II��JJ J
License Number Lie. Class 1 MPROLIF� 6-Ak�T�'
S'T2GlCTf%fR� LIMITED TIME USE
Contractor• DateDATE DATE
EJI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF PRom: To: INSPECTORS
acting in my professional capacity (Section 705 1, Bus- EXISTING BLDG. STORIES SIGNATURE /
inessand,ProfessionsCode). FINAL
PRESENT USE OF BUILDING - APPROVAL '� I "�/ i��G�/t�✓"
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ^11
ON LOT AND USE _
I hereby affirm that I am exempt from the Contractor's AC ) sa _
License Law for the following reason (Section 7031.5, Busi-
ness
•ness and Professions Code): NO. PARKING
' � SPACES PROVIDED 1 ITEMS
I, as owner of the property, will do the work and the ITEMS
i-?
structure is not intended or offered for sale (Section
7044,Business and Professions Code). ' TOTAL 810 _50
e s0
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK
80
\tRC ! u'r•50
I hereby affirm that there is a construction lending agency CHANE
for the performance of the'work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name - - (^ �y(''(}
PROPOSED MAX. OCC. 0000-0001 11/28/P3
Lender's Address ,
I certify that I have read this application and state that the PERMIT FEE (4] t 1 Ate 8:34
70100
above information is correct.I agree to comply with all County ISSUANCE FEE 5 D
ordinances and State laws relating to building construction, a
and hereby authorize representatives of this County to enter TOTAL
upon the v en '�neertyor inspection purposes.
' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dat