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HomeMy Public PortalAbout6411 LOMA AVE_Miscellaneous__ WOIcKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have a certificateof 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 ADDRESSL© ft ADDRESS Co��j5 Certified copy is hereby furnished. BUILDING ADDRESS f //II�I j LOCALITY 6V21 Cr FICertified Copy is filed with the county building mspectlonLO c'ALITY �� NEAREST p Q department. - CROSS ST. V i'I�O rl Date Applicant - -- - NEAREST I +1 DISTRICT p GROUP TYPE MSSED BY CROSS'ST. -�'(�,1/�4J S[ CONST, - CERTIFICATE OF EXEMPTION FROM WORKERS'` LEGAL . (� COMPENSATION INSURANCE'•, DESCRIPTION LOT NO. BLOCK MAF HIGHWAv STATE MAJOR SECOND LOCAL NO, OF BLDGSNO. (CIRCLE) + ,• (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.) USE OF m the size I certify that OF LOT EXISTING BLDG. }� d performance of the work for which this I l permit is issued, I shall not`employ any person in any manner OWNER -*' t IS _ so as to'become subject to the Workeromp�tiQx1 3w.Igo OCCUPANCY GROUP �J MAIL ADDRESS Sa1M " i Date Applicant D w TEL. y / 6 OCCUPANT LOAD NOTICE40 APPLICANT: If, after making this Certificate of CITY No. dL fO Exemption, yduN 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 USE ❑ GEOLOGY INSPECTION❑ No Spec. KnOWI. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencing with Section 700.0) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is'in full force and (� effect. PARKING REQ'D r-� PROVIDED -� "� SPACES LL�� License Number Lic. Class Gq M<1A/ FLI2O0 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 OFNO. OF INSPECTORS acting in my professional capacity (Section 7051, BAs- EXISTING BLDG. 1 STORIES C SIGNATURE iness and Professions Code).. JPIr e� FINAL.APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date tw a e-✓S�. HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS IN ON LOT AND USE - I hereby affirm that I am exempt from the Contractor's- ACCTAL License Law for the following reason (Section 7031.5, Busi- w�� 1u 4*- ( e ness and Professions Code): NO. PARKA t v1 131307 80.50 ness I, as owner of the property, will do the work and the SPACES PROVIDED 1 +I�•Ej'{j' a '- structure is not intended or offered for sale (Section r = 7044,Business and Professions Code). TOTAL. 50 CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING I ; ~`-'1 CHECK a iSA°Cf9 I hereby affirm that there is a construction lending agency Covjewk &U 41D ` .`.CHM for the performance of the work• for which this permit is _ issued(Sec. 3097,Civ.C.). Lender's Name ` Q� PROPOSED MAX. OCC. 0000•-•0001 S//1(l,/v Lender's Address PERMIT FEE 5063 1 IM 5:11 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 upon.the ove-mentioned'pr pert for inspec ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature of Permittee Dat