HomeMy Public PortalAbout10714 LORA ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875(2-80) MISCELLANEOUS APPLICATION
I s e,or a fi rt 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 BADUILDING O /
DRESS
❑ Certified copy is hereby furnished. BUILDING /
❑ � LOCALITY
ADDRESS I
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY , CROSS ST. r
Date Applicant NEARESTDISTRICT NO UP TYPE PRO D BY
CROSS ST. 57 M i � �...� CONST.\
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL — J V
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY }
NO. (CIRCLE) STATE MAJOR SECON LOCAL (1
NO. OF SLOGS.
(This section need not be completed if the Work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.)
USE F
SIZE OF LOT EXISTIONG BLDG. �(�J
O u4 �' Ir
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner OWNER E.
V
so as to become subject to the Workers'Compensation Laws. MAIL – OCCUPANCY GROUP Fk i3 LV
ADDRESS L� �� O_
Date Applicant to
�Z-
NOTICE TO APPLICANT: If, after making this Certificate of clrr OCCUPANT LOAD erly! � No. s -"
Exemption, you should become subject to the Workers' APPLICIATION 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 NO Spec. Knowl. ❑
deemed revoked. Panic DeVIC@S ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (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 N
effect. AWPI 0 D C PARKING REQ'D PROVIDED -�
� SPACES
License Number Lic.Class Lau '^ /✓Cl/
LIMITED TIME USE
Contractor Date DATE DATE
❑ 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- EXISTING BLDG. STORIES ` SIGNATURE
iness and Professions Code). PRESENT USE OF BUILDING 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
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section A 41 3.7 A
7044, Business and Professions Code). PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY # 0 0 0 0 3 0
I hereby affirm that there is a construction lending agency I O o $a J`0
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). o 0 0 $Q 5 0
Lender's Name PROPOSED MAX. OCC.
Lender's Address t1 0 2 2 8-8 6
PERMIT FEE M-00
V
I certify that I have read this application and state that the D
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, ,l
and ereby authorize representatives of this County to enter TOTAL FEE io �(l
up n the abo -mentioned op y f inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date