HomeMy Public PortalAbout5812 MUSCATEL AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) M pSCELLANE®US APPLICATION
I hereby afff;xm that•I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a--.certit`ibate of Workers'Compensation In§urance,or
a ce.-wtifieG copy thereof(Sec.3800,Lab.C.I.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING �� '
ADDRESS
FlCertified co is hereby furnished. BUILDING '�
Py y ADDRESS /r+ LOCALITY ; Y
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant CNEARESTROSS ST. Dls�$I yt o• c�q� ITYPE
Nr�. PR seen BV
u�/�9s vim- 1� Cyb
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. 9CJ BLOCK 4c MA' IGS Y STATE AJOR MND LOCAL
3 NO. (CIRCLE)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT 36 2 3 NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) Lw� EXISTING BLDG.
USE of
w
SIZE OF LOT 11
�I a
I certify that in the performance of the work for which this // o
permit is issued, I shall not employ any person in any manner OWNER =
so as to become subject to the Workers' Compensation Laws. E T. N '
OCCUPANCY GROUP ��� a
MAIL
Date Applicant ADDRESS 73Wi)71)/*e y✓oTEL
111 v
NOTICE TO APPLICANT: If, after making this Certificate of CITY , NO. OCCUPANT LOAD r--- N
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall 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 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 , T ' /�p
effect. / /� 6 we 4.4-6�v /J„ , RKING
SPACES RRQ'D D PROVIDED O
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 engineerSIZE OF / NO.OF INSPECTOR'S
acting in my professional capacity (Section 70SI, Bus- EXISTING BLDG. �' � STORIES SIGNATOR
iness and Professions Code).
PRESENT USE OF BUILDING W 64I*Al FINAL APPROVAL
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'sE WCIL4
Al 61
/ o4
License Law for the following reason (Section 7031.5, Busi !Z GIF
ness and Professions Code): NO. PARK/NG P7 C
i�o
n I, as owner of the property, will do the work and the SPACES PROVIDED _
`4 structure is not intended or offered for sale (Section 7 IrE'I"
7044,Business and Professions Code). i 1 I AL 93 eI
CONSTRUCTION LENDING AGENCY PR P E SE UILD
CHECK 9ME,
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is nf CHANGE j10
issued(Sec. 3097,Civ.C.). `�i g�vw
Lender's Name
PROPOSED MAX. OCC. 011± -330 C/ 3/9".'
/9
LLender's Address
PERMIT FEE !Bob 0
I certify that I have read this application and state that the ;]z7C 7:7'
above information is correct.I agree to comply with all County ISSUANCE FEE 13, 00
ordinances and State laws relating to building construction,
andhereby authorize representat' s of this County to enter TOTAL.FEE i0
upo ove-men ' pr y for inspection purposes.
EE REVERSE FOR EXPLANATORY LANGUAGE
ature of Permittee Date