HomeMy Public PortalAbout6403 LOMA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) M ISCELLAN•EOUS APPLICATION ^
CE 875 r '
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUIL,,DING AND SAFETY DIVISION ,UI
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.Q.
Policy No. Company FOR APP LICANTTO FILL IN BUILDING ,103 • J
ADD,R ESS � p/»(} Q E
Certified copy is hereby furnished. BUILDING 6y�3N • �aMA
ADDRESS PIV{: LOCALITY ,C Ae Le c M
El Certified copy is filed with the county building inspection LOCALITY JNEST
department. MQL�, CITY ST. r" Falor>.
Date Applicant NEAREST CT NO. OUP TYPE P CESSEDY
CROSS ST. COCERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTIONLOT NO. � BLOCK HIGHWAYSTATE MAJOR SECOND LOCAL
(CIRCLE)
NO. OF BLDGS.(This section need not be completed if•the work involved TRACT I q S 0 NOWON LOT NE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) / USE OF /^(
SIZE OF LOT 7 X ' -35 EXISTING BLDG!_w
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 JAQ Pf( � 5 A NT I `-3
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP
0
ADDRESS 1, D3 N. LDMA /;u E �-
Date Applicant w
NOTICE TO APPLICANT: If, after making this Certificate of CITY E .rf THE '1918 041 9-77 OCCUPANT LOAD z
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 GEOLOGY INSPECTION ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
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 RL.I,NGD RaDIY% g�,M
effect. PARKING REQ'D D PROVIDED r--�
SPACES
License Number Lic. Class D6 rj 00t (3 ED B OJ
LIMITED TIME USE
Contractor Date 1 /�539A DI 8-� A /� . FROM: TO:DATE DATE
- d l WP
I am exempt from the licensing requirements as I am a ,
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES / SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING 2
Lic.or Reg.No. Date FINAL APPROVAL
/� '>
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �" /w•�^(� �(
ON LOT AND USE I! `�'
I hereby affirm that I am exempt from the Contractor's �
_ `
License Law for the following reason (Section 7031.5, Busi =fij ; a7�
ness and Professions Code): NO. PARKING
-T
1, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section �. " • I I€HL ,_ ]
7044,Business and Professions Code). �U� ( -
CONSTRUCTION LENDING AGENCY PROPosE SE OF BUILDING /a� " V i:( I^i:K t ,�ectr
I hereby affirm that there is a construction lending agency {GE
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.Q.
Lender's Name s - -•,__
PROPOSED MAX. OCC. III Ili I--fle)i il, 1r. �I!
Lender's Address I;;1�j `es y
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 _ ,3,4�0
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FE 3
upon the above-mentioned property for inspection purposes.
• SEE REVERSE FOR EXPLANATORY LANGUAGE
,,--Sig`ature of Permittee Date