HomeMy Public PortalAbout6417 LOMA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 M I SC E L LA N E O U S APPLICATION
CE 875(11-84)
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
MCertified copy is hereby furnished. BUILDING h,C� LOCALITY
ADDRESS
❑ Certified copy is filed with the county building inspection LOCALITY
NEAREST
department.
�� CROSS ST
Date Applicant NEAREST DISTRICT N6 GP ITYP OC SSE D(By
CROSS ST. CO NST. -
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MNOar ^U✓1G (CIRCLE)
f to lw Av STATE MAJOR SECOND LOCAL
�--•�(� NO. OF BLDG S.
(This section need not be completed if the work involved TRACT .J NOW ON LOT U3 ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or'less.) ( usE OF
I certify that in the performance of the work for which this SIZE OF LOT G4YEXISTING BLDG. O
permit is issued, I shall not employ any person in any manner OWNER ='
so as to become subject to the Workers' Compensation Laws. MAIL l _ OCCUPANCY GROUP �'3
0
AD DR ESS •� �
Date• Applicant, , ` U-3
NOTICE TO APPLICANT• If, after making this Certificate of CITY — NO. 9 C� OCCUPANT LOAD,
Exemption, you should become subject to the'.Workers' O
TION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth- APPLICA ❑
with comply with such provisions Or this permit shall be TRAILER USEGEOLOGY INSPECTION
deemed revoked. E] E] No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION EJ 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 � j —j( Z3
PARKING G PROVIDED
�p(� , SPACES REQ
O
License Number Lia Class ! Z� m� �-
�� 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 INsPECTOR'S
acting in my professional capacity.(Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING r"
Lic or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
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
1, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
I PROPOSED USE OF BUILDING- -` •'� l�� `� =� � �'\ ' •�,��`,
CONSTRUCTION LENDING AGENCY - :
I hereby affirm that there is a construction lending agency
for the performance of.the work for which this permit is ,0 Do30
issued(Sec. 3097,CCivC). - •
# D
Lender's Name I D 80.50
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE ? (�b ,O a o $0.5 0 U
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
ordinanceand State laws relating to building construction, D 0 9,11 -8.6
and her y authorize representatives of this County to enter TOTAL FEE
upon t ab ve-me do ropert for inspec n purposes
_ �_f/� SEE REVERSE FOR EXPLANATORY LANGUAGE .
Signu e of Permitte Date