HomeMy Public PortalAbout6152 MUSCATEL AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875
(11-84) 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 /J�
ADDRESS J
Certified copy is hereby furnished. BUILDING ;
ADDRESS �/ Ga � LOCALITY � ,
Certified copy is filed with the county building inspection LOCALITY d NEAREST
department. 'em e CROSS ST. L d h
Date Applicant NEAREST DISTRICT N/p-� GROU TYPE PROCESSED BY
�DO _
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. 0 `� CONST.LEGAL o0
COMPENSATION INSURANCE DESCRIPTION LOT O. ' BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT 15,q0,qLNOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF ,/1 , eS
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this C:)
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. MAIL , /„ OCCUPANCY GROUP o
ADDRESS 7G '3
Date Applicant el--I
NOTICE TO APPLICANT: If, after making this Certificate of cIT ITvoL 7-3 l OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth El
comply with such provisions Or this permit shall be TRAILER USE GEOLOGY INSPECTION
deemed revoked. No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING RSQ'D PROVIDED
SPACES
License Number Lic. Class ffi1
//�• /' LIMITED TIME USE
Contractor Date �/ a DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:$ ,
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. 1 s STORIES SIMAT
)
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL � ...�
Lic.or Reg.No. Date 1
51
HOME OWNER-BUILDER DECLARATION NO. OF EAJSJZNG BUILDINGS • - �''
ON LOT AND USE (
I hereby affirm that I am exempt from the Contractor's ���� 3ti�� 227°71
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
r'I'v
MS
F7I, as owner of the property, will do the work and the SPACES PROVID TOTAL a-I�2_. 70
structure is not intended or offered for sale (Section U71i°717
7044,Business and Professions Code). CHECK'��CHECK .?
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHANGE .1b
I hereby affirm that there is a construction lending agency 4ff11 11
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). (](31]0-0001 3l 2/9-3
Lender's Name i4 1 1 AM 9:N
PROPOSED MAX. OCG.
Lender's 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
ordinanc and State laws relating to building construction,
and herb authorize re esentatives of this County to enter TOTAL FEE,2-
upon tl bov m tion p erty for inspect'o pur oses.
�_ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee/ Date