HomeMy Public PortalAbout9237 LONGDEN AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION I 76M444
CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself; COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or.�
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. CompanyFOR APPLICANT TO FILL IN PDDR ESS '
FiCertified copy is hereby furnished. ILDING
DDRESS ,,.,.�.. LOCALITY
Certified copy is filed with the county building inspection' OCALITY J T AHUSA RD. UNIT S.
, NEAREST
department. CROSS ST.
Date Applicant .I NEAREST I _ r 9 CA.
_ DISTRICT NO. GROUPTYPE PROCESSED BY
I r
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. CONST.
LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
No. . (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLD GS.
(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 ( o
SIZE OF LOT EXISTING BLDG. I V
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any mannertA,L
LL.
WNER Af _ -1
so as-to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP f M,
ADDRESS >
Date Applicant 4C ~. I • +-+
'Sop
a
NOTICE TO APPLICANT: If, after making this Certificate of \ ITY An NO. OCCUPANT LOAD a
Exemption, you should become subject to the Workers'• t 0,01 ION FOW" EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth- ❑ F
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS'DECLARATION OCCUPANCY INSPECTION 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 Exlrs
ness.and Professions Code,and my license is in full force and
effect. �''"l.i TZ• 1 ��11:y ! PARKING REQ'D PROVIDED
SPACES
License Number Lic. Class
• LIMITED TIME USE •-
Contractor Date !
/ 'iy=. •'�/•7,..'1�� J !�� 1. •! .� ! /' 4 DATE GATE
FROM: TO:
I 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, Bus- rzxIyfiNG BLDG. STORIES SIGNATURE
iness and Professions Code).
RESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
rJ .
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 '
ETI, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY IN OPO-ED USE OF BUILDING
I hereby affirm that there is a construction lending agency '� ;�.; t ��,, : f �) •': r f, ti
for the performance of the work for which this permit is -
issued(Sec.3097,Civ.Q. f• ;,:; - !�f j,. '( ,�`: -t { � ',.�.;=-
tender's Name 0.
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE � G�
I certify that I have read this application and state that the
above information is correct.I a,gree to comply with all County ISSUANCE FEE
ordinances and State laws rel1a�ting to building construction,
and hereby authorize represenfiatives of this County to enter TOTAL FEE tJ
upn the above-mentioned property for inspection purposes.
/ .SEE PVERSE FOR EXPLANATORY LANGUAGE
i 'S'igtiatuie of Permittee Date f ✓ !