HomeMy Public PortalAbout9443 LONGDEN AVE_Miscellaneous__ WORE'R-_1<0MPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I henJl afcertificate
that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,or a of Workers'
rs'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANTTO FILL IN BUILDING
AD
DDR ESS • �
IDCertifiedcopy is hereby furnished. BUILDING )J' ��` d�n �
F-1 Certified
LOCALITY
ADDRESS 'f
Certified copy is filed with the county building inspection i
department. LOCALITY NEAREST
_ C�
CROSS
Q ST.
Date Applicant NEAREST ♦ II DISTRICT.y.qt PUP TY S PRO SED Y
CROSS ST. .e yv l 1 l� (�J`J(Vt/ Yh//3 CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL `
COMPENSATION INSURANCE DESCRIPTION OT No. BLOCK MAP HIGHWAY }
NO. F BLDGS.
NO. (CIRCLE) STATE MAJOR SEC D LOCAL O
(This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS U
by the permit is for one hundred dollars ($100) or less.) USE OF /)
SIZE OF LOT EXISTING BLDG. i r Cr
I certify that in the performance of the work for which this 1 Q
permit is issued, I shall not employ any person in any manner OWNER �`. V
so as to become subject to the Workers' Compensation Laws. MAIL 1 / OCCUPANCY GROUP W
ADDRESS p �-) II 1(/l�_ 't/ ' CL
Date Applicant 1' f p /
NOTICE TO APPLICANT: If, after making this Certificate of CITY WIIEO`rCp�l iriC�/ NO�`Ol�,�l� OCCUPANT LOAD ?
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION N ❑
deemed revoked. ❑ OSpec. Kt10Wi. ❑
OCCUPANCY INSPECTION
LICENSED CONTRACTORS DECLARATION C] 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
effect. enxyc agm PARKING
SPACES REO'D D PROVIDED O
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 OFNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SI ATURE
iness and Professions Code). FINAL APPROVAL A14II
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
NO.OF EXISTING BUILDINGS
HOME OWNER-BUILDER DECLARATION
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- ;9347. 1 A
ness and Professions Code): NO.PARKING
SPACES PROVIDED # 0 0 0 03 0
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section I o o $a 5 O
7044,Business and Professions Code). PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY D o o8(15030:
I hereby affirm that there is a construction lending agency
for the performance of the work for wjtich this permit is 1 1. 1 4�8 5
issued(Sec. 3097,Civ.C.).
Lender's Name PROPOSED MAX. OCC.
Lender's Address PERMIT FEE D
t.
I certify that I have read this application and state that the -
above information is correct gree to comply with all County ISSUANCE FEE yy� p,(/J, 1,
ordina ces and State 1 relating to building construction, �C�9/"t'�'C�`¢s iG� 4 57—76 Ott
and h eby authoriz epresent��Ives of this County to enter TOTAL FEE
upon heove- tinned >5perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
r1l Signature of Pe tttee Date