HomeMy Public PortalAbout5826 MYDA AVE_Miscellaneous__ WORNiRS'COMPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION
. _, � 1 CE 875(11-84)
I hereby 'a cert'certificate
I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or'a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.).
BUILDING
Policy No. Company FOR APPLICANT TO FI LL IN
ADDRESS
❑ Certified copy is hereby furnished. BUILDING 92/ Q/Q ye LOCALITY
ADDRESS 6
DCertified copy is filed with the county building inspection LOCALITY1 NEAREST
department. �� l CRoss ST. Q
Date Applicant NEAREST � � DISTRICT NY GR `TYPE / PR SS BY
CROSS ST. U PYA/ 1/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. #10 BLOCK MAPIOM-Av
NO./ U�eIRCLE) STATE MAJOR SEC613 LOCAL
C NO. OF BLDG 50
(This section need not be completed if the work involved TRACT vs NOW ON LOT / U ZONE SP IAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE
of
I certify that in the performance of the work for which this SIZE OF Lor_To K��� EXISTING BLDG. Q E.S „ o
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 GROUPYE
a
Date Applicant ADDRESS �d2 E3
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tiy/ rNEOL" S �6 OCCUPANT LOAD
Exemption, you should become subject to the Workers' —
Compensation provisions of the Labor Code,you must forth- A LICATION FOR EXIT HARDWARE:
with comply With such provisions oI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION J4 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 r
effect.
PARKING REq'DPROVIDED
'�� SPACES
License Number Lic. Class L�/ @ (��j/h�9i d eQ-
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
I am exempt from the licensing requirements as I am a h Q/'
licensed architect or a registered professional engineer SIZE OF NO.OF r INSPECTOR'S
EXISTING BLDG. S STORIES / SIG ATURE
acting in my professional capacity (Section 7051, Bus- r� A 1S
iness and Professions Code). FINAL APPROVAL �/lo
PRESENT USE OF BUILDING ((11
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's f
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
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 9 6 2 9.9 A
I hereby affirm that there is a construction lending agency # 0 0 D 0 30
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q. D o 8 a 5 0
Lender's Name
PROPOSED MAX. D.C. 0 - 80.50
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the 0 1. 0 7—S 7
above information is correct.1 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 a above-mentioned property for inspection purposes.
� / ��` / 6,�7 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date