HomeMy Public PortalAbout8637-8639 LONGDEN AVE_Miscellaneous__ cl�"r WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
11ureaffirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,, o 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 /17
Certified copy is hereby furnished. BUILDESS �
ING /
ADDR �1 LOCALITY
0 Certified copy is filed with the county building inspection LOCALITY NEAREST � Q
department CROSS SST
Date Applicant NEAREST DISTRICT NO GR UP TYPE P O SSED BY
CROSS ST. Jr, �8 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL `{
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY
NO (CIRCLE) STATE MAJOR SECOND LO
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.) USE OF
SIZE OF LOT EXISTING BLDG.
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
so as to become subject to t rkers' Compensation Laws. MAILOCCUPANCY GROUP �j a
h �6 ADDRESS I--
Dat .,1Applican L`LI
NOTICE TO APPLICANT If, after making this Certificate of CITY 16 NoL OCCUPANT LOAD
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. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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
effect 1 s d�J PARKING REQ'D PROVIDED
SPACES LTJ
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM TO'
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF No OF IN3PE CTO R'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S GNATURE
mess and Professions Code)
,Ol l
PRESENT USE OF BUILDING FINAL APPROVAL ✓
Lie 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
I, 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).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is ACCT.4
issued(Sec. 3097,Civ.C.).
Lender's Name 3307 80{,0
PROPOSED MAX. OCC.
Lender's Address1 ITEMS
PERMIT FEE
I certify that I have read this application and state that the y�q� •� �_
above information is correct 1 agree to comply with all County ISSUANCE FEE Q TOTAL r1f_ _B3
ordinances and State laws relating to building construction, C HECY �I a I E
and hereby authorize representatives of this County to enter TOTAL. FEEQ
u_p
ti property property for inspection purposes. CHANGE p�_'•_E
/`//i h SEE REVERSE FOR EXPLANATORY LANGUAGE
p 0
Signature o ermittee Date (?I]I?�1_!�i j�!i 1!j '!'=Ij
072 i Art 8 13,1