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HomeMy Public PortalAbout6129 MUSCATEL AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION M I SC E L LA N EO U S APPLICATION CE 875(11-84)875 tir� CE I'liefeby 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.Q. BUILDING Policy No. Company FOR APPLICANT TO FILL IN y ADDRESS Certified copy is hereby furnished. BUILDING LOCALITY I ADDRESS I� N. C DCertified copy is filed with the county building inspection LOCALITY NEAREST /� department. AANI ►1? CROSS ST. tu'l �1 Date Applicant NEAREST DISTRICT Q� GR TYPE 111C!7D BY CROSS ST. FIC , CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SEC D LOCAL NO. OF BLDGS. (This section need not be completed if the work Involved TRACT (J NOW ON LOT US ZO E SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) J) USE of I certify that in the performance of the work for which this SIZE OF LOT VJV EXISTING BLDG. o permit is issued,I shall not employ any person in any manner Ow M4,6V y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADDRESS G~] Date Applicant I„ TEL' OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of clTr No. - N Exemption, you should become subject to the Workers' MW z Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions OI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. KnowL deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCC\IPANCY INSPECTION`( 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 effect. J PARKING SPACES REQ'D PROVIDED License Number Lic. Class © f 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 INSPECTOR'S acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL I .� A PRESENT USE OF BUILDING l Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS I ° S n 5 U Z ON LOT AND USE O O O 3 Q,5 p 6 I hereby affirm that I am exempt from the Contractor's 11.,i 6-8 8 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 LEI 1 5,C A structure is not intended or offered for sale (Section 7044,Business and Professions Code). # G o G D j PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I c. 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 11. 'I d 8 8 PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE 1/' above information is correct.I agree to comply with all County ISSUANCE FEE Q ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon the yboveA:ntion d property for insl ectio purp "'L-Sign'a't'u're�I � D � SEE REVERSE FOR EXPLANATORY LANGUAGE of Permittee Dat