HomeMy Public PortalAbout5517 NOEL DR_Miscellaneous__ WORKERS COMPENSATIOV DECLARATION
CE 875(11 84) M I SC E L LA N EO U S APPLICATION
CE 875 n
1 hereby affirm that I have a cgrtificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ,IL JII
insure or a certificate of Workers Compensation Insurance
e or ,
a certified copy thereof(Sec 3800 LabX) I I
Policy No Company FOR%PPLICANTTO FILL IN BUIADDREssG LDIN45�5c /7 mr_v be-
E] Certified copy is hereby furnished BUILDING 5517 Noel Dr J
ADDRESS LOCALITY
1 Certified copy is filed with the county building inspection LOCALITY Temple C 1 ti NEAREST
department CROSS ST
Date Applicant NEAREST N Broadway W/Encinitas DISTRICT}VO GR� TYPE PRO 86D Y
CROSS ST �0S CONST Jr
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO 17 IBLOCK 1 MAP HIGHWAY
OF NO ICIRCLE) STATE MAJOR SECON LOCAL
(This section need not be completed if the work Involved TRACT 4812 l7 NOW ON LOTS 1 USE ZONE SPECIAL 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 LOT 10, 980 EXISTING BLDG SFR
permit is issued I shall not employ any person in any manner OWNER \74 erl E cHe-A/ s
so as to become subject to the Workers Compensation Laws •� A' �J OCCUPANCY GROUP /�,3 cc
MAILADDRESS Sv /7 "_&✓"' Ak t
Date Applicant c� 1J
NOTICE TO APPLICANT If after making this Certificate of CITY T �'/
TE
4481— 2/Z Z OCCUPANT LOAD y
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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑
Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT LIST ITEMS BEU
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 A7/tj E)VCLO9()XF ? 2,VPARKING
effect REO DD PROVIDED
SPACES D
License Number Lie Class
2�PL�cr LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO OF FROM TO INSPECTOR S
acting in my professional capacity (Section 7051 Bus
BXISTIN6 BLDG 1944 STORIES 2 SI6 TUK
mess and Professions Code) RE sidental FINAL APPROVAL
Lie or Reg No Date
PRESENT USE OR BUILDING i. ��•,15-
HOME
5HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS , � �I 30
ON LOT AND USE
I hereby affirm that I am exempt from the Contractors ACCT■`.
License Law for the following reason (Section 70315 Bust �n�
ness and Professions Code) NO PARKING s �7.71J.7 242.0
I as owner of the property will do the work and the SPACES PROVIDED 1 ITEMS
structure is not intended or offered for sale (Section TOTAL 242.70
7044 Business and Professions Code) PROPOSED USE OF BUILDING /QFS/QM;r/&L— CECK 242.70
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 4' dGE .00
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
Lender s Name x-0001 10/M/99Lender s Address PROPOSED MAX occ
I certify that I have read this application and state that the PERMIT FEE X51 1 AM 9:44
above information is correct I agree to comply with all County ISSUANCE FEE a 340
ordinances and State laws relating to building construction
and hereby au orize r resentatrves of this County to enter TOTAL FEE , D
upo a abov menti d pro arty for inspection purposes
?Jr SEE REVERSE FOR EXPLANATORY LANGUAGE
�41Srliitnrre6➢a ee Date