HomeMy Public PortalAbout8919 LONGDEN AVE_Miscellaneous__ ,ems 1N,QRKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby*s'ffirm 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. BUILDING LOCALITY
ADDRES'S
❑ Certified copy is filed with the county building inspection NEAREST
department. LOCALITY CROSS ST'. 4- .
Date Applicant NEAREST DISTRICT NO, ROUPfliTYPE PROCESSED BY
CROSS ST. CONST:
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALt L
COMPENSATION INSURANCE DESCRIPTION LOT NO. B! LpdsK MqP HIGH Wqy }
NO. (CIRCLE) STATE MAJOR SECON OCAL a
NO. OF BLDGS. O
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONH11 PECIAL CONDITIONS 0
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT 4 &, eEXISTING LDG. cr
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 U
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP W
ADDRESS - CL
Date Applicant n �, N
NOTICE TO APPLICANT: If, after making this Certificate of CITY 04Z clt NO. OCCUPANT LOAD '+�
Exemption, you should become subject to the WorkersAPPLICATION 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
deemed revoked. ❑ ❑ No Spec. Knowl. ET
LICENSED
-
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) ❑
NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING. I��
effect. SPACES RE U PROVIDED
License Number Lic.Class
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 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 IV FINAL APPROVAL
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
SPACES PROVIDED
❑ �as owner of the property, will do the work and the IF
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
PROPOSED USE OF BUILDING - ,Z 91 3.4 A
CONSTRUCTION LENDING AGENCY
'•LAereby affirm that there is a construction lending agency .#,o 0 0 0 30
for the performance of the work for which this permit is 01e- +
issued(Sec. 3097,Civ.C.). h 0 o 8 0.5 0
Lender's Name PROPOSED MAX. OCC. OI O o 0 5 0 M
Awl
Lender's Address PERMIT FEE 149 r—
I certify that I have read this application and state that the .01 1 7—8 3
above information is correct.I agree to comply with all County ISSUANCE FEE Q r�
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
!�tlbove- entione pr erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
1 I7 8�
Signature of Permi tee Date