HomeMy Public PortalAbout10420 MILOANN ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 87b(17-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec.3800,Lab.C.). `
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
pDDR ESS ^ /{
Certified copy is hereby furnished. BUILDING �� �
ADDRESSOY
LOCALITY
DCertified copy is filed with the county building inspection LOCALITY ' T NEAREST
department. �LL� / r CROSS ST.
Date Applicant NEAREST DISTRICT yO G P TYPE PROCESSED BY
CROSS ST. I ,`// �� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL U{Y7
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE[)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE SIZE OF LOT EXISTING BLDG.
of
I certify that in the performance of the work for which this Ci
permit is issued, I shall not employ any person in any manner OWNER L L,,c
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP a
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of CITYL dV&ft 7106 /r/JnioI_- 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.
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 II '• X 3 0 ��rZ l�-Pfd f�"
effect. PARKING SPACES REQ'D D PROVIDED D
License Number Lic. Class
�L�lT.�iJ c LIMITED TIME USE
Contractor Date DATE DATE
0 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 SIG ATURE
iness and Professions Code).
PRESENT USE OR BUILDING FINAL APPR
Lic.or Reg.No. Date OVAL t J j"
L / /J /��f
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ;261 S G R
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING # D D o D 3 0
I, as owner of the property, will do the work and the SPACES PROVIDED IDD 8 Q 5 0
structure is not intended or offered for sale (Section
7044,Business and Professions Code). D D o 8 Q 5 0�
CONSTRUCTION LENDING AGENCY
PROPOSED USE OF BUILDING 1 222-86
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 ItA
I certify that I have read this application and state that the PERMIT FEE :71)I
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 bove-mentioned property for inspection purposes.
��A� ,� /w/�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee H Date