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Home My Public Portal About5429 MCCULLOCH AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION a CE 875(11-84) MISCELLANEOUS APPLICATION ' CE 87 I hekeby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO-FI LL IN J'AD jA �` �•�' S 41 Certified copy is hereby furnished. BUILDING ADDRESS Certified copy is filed with the county building inspection LOCALITY department. Tei ' Date Applicant NEAREST �r?1 o. GR UP TYPEPROC S EOBYCROSS ST. �� CONST, /CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALbvCOMPENSATION INSURANCE DESCRIPTION LOTNO. BLOCK C NIGNWAY STATE MAJOR SECO LOCAL (CIRCLE) NO. OF BLDGS.(This Section need not be completed if the work involved TRACT' NOW ON LOT PECIAL CONDITIONS by the permit is for one hundred dollazs ($100) or less.) pUSE OF iSIZE OF LOT O X7©0EXISTING BLDG. I certify that in the performance of the work for which this �/ v o permit is issued, I shall not employ any person in any manner OWNER '' d„ w ( —� so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP I Y'KI i ✓�j I o ADDRESS ~ Date Applicant L"L+ NOTICE TO APPLICANT: If, after making this Certificate of CITY ' TN.-�7 OCCUPANT 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 11 ❑ No Spec. KnowL deemed Ievoked. TRAILER USE GEOLOGY INSPECTION LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices 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 EXITS ness and Professions Code,and my license is in full force and • r effect. PARKING RoaSPACES REQ'D D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF FROM: TO: INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING 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 r 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 o structure is not intended or offered for sale (Section z 611.7 A 7044,Business and Professions Code). } # O O O D 3 O CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency a o o $ S 0 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). D - 80,505) Lender's Name 1 2_16-86 PROPOSED MAX. OCC. Lender's Address 1 D , PERMIT FEE _70I 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 U upo the above-mentioned property for inspection purposes. _ 8 SEE REVERSE FOR EXPLANATORY LANGUAGE O Si Lure of Permittee Date