HomeMy Public PortalAbout5035-5037 MCCLINTOCK AVE_Miscellaneous__ /"WORKERS'COMi?ENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION v
+ CE 875(11-84)
I hereby affirm that I have a certificate of consent. self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Worker's'Compensation Insurance,e,or
'certified copy thereof(Sec.3800,Lab.C.).
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING
ADDRESS ✓
Certified copy is hereby furnished. BUILDING ,jr 1
• ADDRESS Q _ LOCALITY �"�`G
DCertified copy is filed with the county building inspection
department. p LOCALITY NEAREST
CROSS ST. �
Date Applicant NEAREST DISTRICT NO//' GROUPTYPE PROC SED BY
CROSS ST. /.C1 CONST-./
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL U!x/ V
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. OBLOGS. NO. (CIRCLE)
19
(This section need not be completed if the work involved TRACT ,3 F
NOW ON LOT USE/ZONE SP6 CIAL CONDITIONS
by the .permit is for one hundred dollars ($100) or less.) USE OF• n f I
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
permit is issued,I shall not employ any person,in any manner OWNER
so as to become subject to the Workers' Compensation Laws. MAIL , OCCUPANCY GROUP o
' S '
Date ADDRESS Z3 Applicant -
NOTICE TO APPLICANT: If,after making this Certificate of CITY NO.. 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 ❑ No Spec. Knowl.
deemed revoked. E] Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION i El
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
.mess and Professions Code,and my license is in'full force and
effect. PARKING REQ'DPROVIDED
SPACES O D
License Number Lia Class LIMITED TIME USE 1
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a
PROM
licensed architect or a registered professional engineer SIZE OF NO.OF,
. To. INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
'-i
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE 2 8 5 4,8 A 1
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- # " " a 0.30
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED ti I • • 8 0 5b
structure is not intended or offered for sale (Section
7044,Business and Professions Code). . c • 8 a 5 0 F
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
1208--87
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is "
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC. '
Lender's Address
I certify that I have read this application and state that the PERMIT FEE 1
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 Pt4mittee Date