HomeMy Public PortalAbout9522 LEMON AVE_Miscellaneous__ WORKERS,COMPENSATION DECLARATION - CE 876(2-80) MISCELLANEOUS APPLICATION
I rhereby 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
t!certified copy thereof(Sec 3800,Lab.C)
Fjihcy No Company FOR APPLICANT TO FILL IN BUILDING '
- ADDRESS
❑ Certified copy Is hereby furnished. aDDREss Aja � b U LOCALITY
Certified copy Is filed;with the county building inspection Y NEAREST r
'LOC ALtTY
department T �f e U / ( D CROSS sT
Date • Apphcar 'NEAREST .DISTRICT NO GR �TY•PE RO SSED BY
' - -
CROSS ST. !j CONST.
CERTIFICATE OF EXE,,IPTION FROM WORKERS' - -LEGAL
COMPENSATION INSURANCE DESCRIPTION Lot NO BLOCKOP (CIRCLE) >_` ( I STATE MAJOR SECOND LO C'AL d.
NO. OF BLDGS, '
(This- section need not be completed if the work involved TRACT NOW ON LOT Lis E ZONE' SPECIAL CONDITIONS Q
by the permit is for one hundred dollars ($100) or less.) U
., USE OF j -
' Aperson
SIZE OF L_OT EXISTING BLDG.-I certify that in the performance of t6iman
s 'T7' 0
perm0ec
shall note loy anr OWNER- e �so assubject'to t o MAIL G � OCCUPANCY GROUP I W
DatApplica ADDRESS I&q �
NOTLICANT If, after makirig•this ificate of CITY �� - NO, 7�� 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 "
❑ ❑ r No Spec. Knowl. ❑
deemed revoked Panic Devicds ElLICENSED CONT RACTORS'DECLARATION occuPArycv wsPECT10N
I herebyaffirm that I am lieensed`under I
plOVlslOrlS Of Chapter SAFETY PERMIT'q .(LIST ITEMS'BELOW) ry0 OF EXITS
9•(commencing with Section 7000) of Division 3 of the Bust- _
ness and Professions Code, and my hcense'is'm full force and 3
effect PA-lio r PARKING:
_ SPACES REO'D PROVIDED .
License Number Lic Class
I JI G— /oo,+q ®� O� LIMITED TIME USE
Contractor Date DATE DATE
FROM To
1,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',sBUs- EXISTING BLDG. STORIES SIGNATURE
mess and Professions Code). - FINAL APPROVAL n
PRESENT USE OF BUILDING /`t �[�,�' -� -•��
Lic.or Reg No Date on§
NG
HOMEON LOT
AND UUSEOWNER-BUILDER DECLARATION NO S USE
BUILDINGS
� _ 3 ,
I hereby affirm that I am exempt from the Contractor's 0 J� 1.9 A' '
License Law for the following reason (Section 7031 5, Busr- ,
ness and Professions,Code) NO PARKING
SPACES,PROVIDED _ (6-O `m Z O
❑ I, as,owner of the property, will do the work and the iF - tJ'
structure*is,not intended or offered-for sale (Section ,20,* 8 0,5 0
7044, Business and Professipr s Code). /
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I,hereby affirm that there is a_construction lending agency, 0 Q 1 6—8'4
for the performance of the work ,for which this permit Is
Issued(Sec 3097,Civ-C) -
Lender's Name o PROPOSED MAX. OCC
Lender's Address-4PERMIT FEE �� ^ • - ` '
;I certify-that I'have read this.application end state that the
above Information is correct I agree to comply with all County 'ISSUANCE FEE
ordinances.and State'-laws relating ❑ding,constructlon' TOTAL FEE °
and hereby authorize re rese v o this County to enter
u th ove=m ntt ed o er f r' spec
ti u os SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permrtte Date