HomeMy Public PortalAbout5510 MCCULLOCH AVE_Miscellaneous_8/9/1985_ WOp.WKFPS'1:OM1'ENSATIONDECLARATION 875(2-80)
CE MISCELLANEOUS APPLICATION
CE$75
I hereby affirm that I have certificate of consent to self COUNTY OF LAS ANGELES BUILDING AND SAFETY DIVISION
insure, o?'a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
BUILDING
Policy No. Company FOR APPLICANT TO FILL IN
ADDRESS
❑ Certified copy is hereby furnished. BUILDING AJJ2 //� LOCALITY�rI
❑ ADDRESS
Certified copy is filed with the county building inspection �+ NEAREST
department. LocwLlry / CROSS ST. {J
Date Applicant NEAREST /(G DISTRICT NO. G7-5
UP TYPE JPROCrES*ftO BY
CROSS ST. � CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY }
NO. (CIRCLE( STATE MAJOR SECON LOCAL (L
NO. OF BLDGS. 17
(This S0Ct10n need not be completed if the work involved TRACT NOW ON LOT J USP�l
PECIAL CONDITIONS U
by the permit is for one hundred dollars ($100) or less.) "' OF
SIZE OF LOT;?0 10 EXISTING BLDG.
I certify that in the performance of the work for which this Q
permit is issued, I shall not employ any person in any manner OWNER 5"0/y O Z /, 1--
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP Lll
ADDRESS
Date Applicant U)
NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. 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 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 I--I (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
p
effect. l � �N PARKING REO'D == PROVIDED
SPACES
License Number Lic.Class
LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INS
CTOR'S
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SI NATURE
iness and Professions Code). ,�D�^- � n f
PRESENT USE OF BUILDING FINAL APPROVAL�Q
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' ;2 2 6 S 8 A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
O O O O J O
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the I D - 8050
structure is not intended or offered for sale (Section
7044, Business and Professions Code). PROPOSED USE OF BUILDING o D D 8 0.5 C 5
CONSTRUCTION LENDING AGENCY () a O 9—8 5
I hereby affirm that there is a construction lending agency
for the performance of the work for w.11ich 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 'y
above information is correct.I agree to comply with all County ISSUANCE FEE (J
ordinances and State laws relating to building construction, TOTAL FEE
and hereby authorive representatives of this County to enter
up n gbove- tioned property for inspection purposes. SSE REVERSE I OR EXPLANATORY LANGUAGE U
Signature of P tteeo Date
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