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Home My Public Portal About9817 MILOANN ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 I hereby affirm that I have a certificate of consent to self CE 875(11-84) MISCELLANEOUS APPLICATION 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 FILL INADDRDDR ESSS N Certified copy is hereby furnished. BUILDING �' ,+ LOCALITY ADDRESS ts Certified copy is filed with the county building inspection LOCALITY /' NEAREST department. Gy—tQL� t-Z cRoss sr. Date Applicant NEARESTDISTRICT NO. GROUP TYPE P CESSED BY CROSS ST. Cp CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 0 V COMPENSATION INSURANCE DESCRIPTION LOT NO. ` BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL le NO. OF BLDGS. NO. (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) usE of SIZE OF LOT I 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 OWNER s� so as to become subject to the Workers' Compensation Laws. MAIL _ OCCUPANCY GROUP o ADDRESS R O �P U Date Applicant a- rEL. OCCUPANT LOAD NOTICE TO APPLICANT: If,after making this Certificate of CITY-T'CN Pl_a 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 sliall be TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFE Y 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 effect. � / PARKING SPACES REq'D PROVIDED License Number Lic. Class wxello 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 DF NO.OF INSPE TO R'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG.A�i7t" N _ (Pow STORIES sI ruse iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING tN mL e Lic.or Reg.No. Date Res HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS� ON LOT AND USE yy G I hereby affirm that I am exempt from the Contractor's 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 _ L - structure is not intended or offered for sale (Section _ 7044,Business and Professions Code). is'•aL �;__; _ :„��; CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING py I Hereby affirm that there is a construction lending agency for the performance of the work for which this permit is �� `=�I,•�t� : _- issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lendges Address I certify that I have read this application and state that the PERMIT FEE above information is correct.I agree to comply with all County ISSUANCE FEE _7 ` ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE :E upe above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE D Si nat re of Permi LeeJ, U Date 1 7GM444-CE08784-67 MISCELLANEOUS APPLICATION. 1 COPNTY OF LOS ANGELES MPARTMENT OF COUNTY ENGINEER BUItDISS c ADDRESS ♦�r ' Q St- .BUILDING AND SAFETY DMSION JOHN A. LAMBIE. COUNTY ENGINEER LOCALITY Cl�y- COLEMAN W.JENKINS,SU�P'T. OF BUILDING N.EARS . TTE - _ CROSS S , FOR APPLICANT TO FILL IN DISTRICT NO. GROUP TYPE I P CESSED BY CONST. BUILDINGADDRESS Ld �G � �, MAP (COR CLE) a + N0. STATE MAJOR SECOND LOCAL LOCALITY L°C. USE ZONE SPECIAL CONDITIONS CROSS'ST ST... pjZ;6r!/Z-r;-t:. LEGAL REQUIRED. YARD H.WY STREET NAME EXIST. DESCRIPTION LOT N.O. BLOCK SETBACK WIDTH FRONT NO. OF BLDG'S. P.L,_ TRACT to NOW ON LOT SIDE USEOF SIZE OF LOT I EXISTING BLDG. - OWNER 1,�J ADDRESS ` �/ `6' �li�G'..�Yi(J�i�Gf� �,�..L`'Y (O �1..:- ..�L�r� ✓� �'J!`- CITY ftiG iLi TSL. !/D,�'v' 7l 7G //_./?/_ZLl� CD APPLI TION OR JP�•!`!%/ rte— OCCUPANC'Y ' m INSPECTION SAFETY PERMIT TRAILER USE CL C07: USE OF STRUCTURES OR DEVICES Z LIMITED TIME USE DATE DATE FROM: TO: APPROVALS DATE INSPECTOR'S SIGNATURE OCCUPANCY APPROVAL 1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS GROUP OCC. LOAD ' APPLICATION AND STATE THAT THE ABOVE IS.COR- - RECT AND AGREE TO COMPLY WITH ALL COUNTY TRAILER USE ORDINANCES AND STATE LAWS REGULATING SUCH - WORK AS INDICAT HEREO;4. SIGNATURE OF ✓ z� � SAFETY PERMIT PERMITTEE TEMPORARY STRUCTURE APPROVED ADDRESS " --� TEMPORARY UG TR.UCTURE REMOVED . FEE-$ �C3 FINAL APPROVAL APPLICATION VALIDATI`� JOHN F. LEWIS, PRINCIPAL STRUCTURAL ENGINEER (NOT A PERMIT) cK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH