HomeMy Public PortalAbout5357 MCCULLOCH AVE_Miscellaneous__ RS'COMPENSATION DECLARATION MISCELLANEOUS APPLICATION
CE 875 (2 80)875
�' CE
_. Icert that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
fie, or a certificate of Workers'
rs'Compensation Insurance,or,
.certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
❑ pOD REBS �! y,
Certified copy is hereby furnished. BUILDING
A.... •ot j-
❑ Certified copy is filed SS w, `. LOCALITY with the county building inspection NEAREST
department. LOCALITY 4sy ! • CROSS ST.
Date Applicant NEAREST DISTRICT NO. G U TYPE PR SSED BY
CROSS ST. C C - CONST. 1/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL S d Y
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP C HIGHWAY }
Ho: J (CIRCLE) STATE MAJOR SEG D LOCAL (1
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT ' USE ZONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars ($100) or less.)
USE J q
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner GWNER Tt � ,�-1' O
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP [!—G� C.)
MAIL ``�� ( /^ /' I�_JLU
ADDRESS F/S_q L V�J//�jG �� CL
Date Applicant J 2
NOTICE TO APPLICANT: If, after making this Certificate of CITY-rt L`-1"7/r 16-L TEL.
. L/f/".22OCCUPANT LOAD
Exemption,.you should become subject to the Workers' APPLICATION 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 11 No Spec. Knowl. ❑
deemed revoked. � Panic DeVICOS ❑
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
effect. PARKING.
�• REWO O PROVIDED
SPACES
License Number Lic.Class
LIMITED TIME USE
Contractor Date DATE DATE
r_1FpOM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF j NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. /� � �r STORIES S1 NATURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL15
Lic.or Reg.No. Date (�J
>r !
NO.OF EXISTING BUILDINGS ' I/%/
HOME OWNER-BUILDER DECLARATION ON LOT AND USE ;219 a 3 A
I hereby affirm that- I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- # 000830
ness and Professions Code): NO.PARKING
SPACES PROVIDED
❑ I, as owner of the property., will do the work and the I O 0 8 Q 5 Q
structure is not intended or offered for sale (Section =
7044, Business and Professions Code). o o o 8 a 5 Q v
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY o 5 0 6=8 5
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.C.).
Lender's Name PROPOSED MAX. OCC.
Lender's Address PERMIT FEE
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 ws relating to building construction, TOTAL FEE {'
and hereby a ioriz epresentatives of this County to enter V Isa
upon a e-meyff6ned property for inspection Purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
u 0f ermittee Date