HomeMy Public PortalAbout9709 LONGDEN AVE_Miscellaneous__ W(3'RfiEIYS''COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION �(
I hereby affirm that I have a certificate of consent tself CE 875 (11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insdre, or a certificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING C'
ADDRESS � I
Certified copy is Hereby furnished. BUILDING C: - //1�
ADDRESS t✓' I Le/V c L •f���/ LOCALITY J t
Certified copy is filed with the county building inspection LOCALITY NEAREST r
department. CROSS ST.
Date Applicant NEAREST �(✓rr DISTRICT NO. GROU TYPE OC SSED BY-
CROSS ST. /�� / � C. ST.�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 19
COMPENSATION INSURANCE DESCRIPTION LOT NO. L6 BLOCK MAP HIGw 4 STATE MAJOR SECOND LOCAL
(CI C
NO. E)
1 9 NO. OF ]SLOGS.
(This section need not be completed if the work involved TRACT SI;A/II1 J1�IIM C l+0 NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) ,, �'rl/ / us9 OF
SIZE OF LOTx 3 / EXISTING BLDG. _v
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 R�, ( A L 19 QC-2—
so as to become subject to the Workers' Compensation Laws. MAIL ' p OCCUPANCY GROUP o
Date Applicant ADDRESS 7 �N J i
NOTICE TO APPLICANT: If,after making this Certificate of CITY C/�� NOL !RJ7`L OCCUPANT LOAD
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code,you must forth- APPL ATION FOR EXIT HARDWARE:
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
1 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. `15& PARKING REq'D D PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
EJ 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 SP NATURE
iness and Professions Code). FINAL APPROVAL ' f
PRESENT USE OF BUILDING CS�� •-�/����
41
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ) r `,
ON LOT ANO USE
12 z, � `�)V /�/�.`
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- To/L4 [:
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 S le$7 3 2 A
I hereby affirm that there is a construction lending agency ' o D D 0 3 Q
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). 1 - - 8(150
Lender's Name DDD $0, 5 0 5
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE O 1.08-88
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-ment�e prope y for inspection purposes.
'TaOSEE REVERSE FOR EXPLANATORY LANGUAGE
Signa ure of Permitte Date