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HomeMy Public PortalAbout10715 LORA ST_Miscellaneous__ IVaOI?1�.z ENSATIONDECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION insure, m cert that 1 have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certifll:ate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING ADDRESS O LOCALITY C Certified copy is filed with the county building inspection LOCALITY NEAREST a department. C (\ CROSS ST. Date Applicant NEAREST DISTRICT N OUP TYPERO SSED,BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL YOU COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP ���HIGHWAY STATE MAJOR SECOND LOCAL NO. OF BLDGS. S�' No. / (CIRCLE) �+ (This section need not be completed if the work involved TRACT NOW ON LOT U�V SNE SPECIAL CONDITIONS �/J� O- by the permit is for one hundred dollars ($100) or less.) NO. of r� SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this W rvicee(�G(!1� o permit is issued,I shall not employ any person in any manner OWNER .1 y so as to become subject to the W rkers' o ensation Lawr MAIL OCCUPANCY GROUP o ] P ,f ADDRESS s Date Applicant d�u� W NOTICE TO APPLICANT: If, after making this Certificate of CITY NOEL.. s.� OCCUPANT LOAD y Exemption, you should become subject to the Workers' z 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 No Spec. Knowl. deemed revoked. OCCUPANCY INSPECTION (l� Panic Devices LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS DELOW) 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. PARKING ,_ © Q SPACES REq'D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM: TO: INSPECTOR'S licensed architect or a registered professional engineer SIZE OF NO.OF SIGMA URE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. los STORIES iness and Professions Code). - PRESENT USE OF BUILDING FINAL APPROVAL � .. � � �/� .• C �" Lic.or Reg.No. Date -L HOME OWNER-BUILDER DECLARATION LLO ISTING BUILDINGS D 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 I, as owner of the property, will do the work and the SPACES PROVIDED cL structure is not intended or offered for sale (Section 7044,Business and Professions Code). 0 5 6 1.7 A CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING # 0 0 0 0 6 0 I hereby affirm that there is a construction lending agency I o - 8050 for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. o - 80505 Lender's Name PROPOSED MAX. OCC. I G10-86 Lender's Address P10 I certify that I have read this application and state that the PERMIT FEE . v 6 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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date