HomeMy Public PortalAbout5745 OAK AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875(280) MISCELLANEOUS APPLICATION
I hereby affirm that 1 have 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
ADDRESS
❑ Certified copy is hereby furnished BUILDING LOCALITY
❑ ADDRESS
Certified copy is filed with the county building inspection y, a NEAREST
department LOCALITY / CROSS ST
Date Applicant NEAREST DISTRICT NO GROUP TYPE PR CUSSED BY
CROSS ST (��� S CONST
l
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO BLOCK
MAP HIGHWAY
No O (CIRCLE) STATE MAJOR SECOND LOCALNO OF BLDG
}
(This section need not be completed if the work involved TRACT NOW ON LOTS USE ZONE I SPdFrIAL CONDITIONS 0
by the permit is for one hundred dollars ($100) or less) us LOP V
SIZE OF LOT EXISTING BLDG Q
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner OWNER O
so as to become subject to the Workers'Compensation Laws MAIL OCCUPANCY GROUP U
ADDRESS W
Date Applicant �-
N
NOTICE TO APPLICANT if after making this Certificate of CITY TEL
OCCUPANT LOAD
Exemption you should become subject to the Workers APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be TRAILER USE 0 GEOLOGY INSPECTION ❑
deemed revoked ❑ NOSpec KnOwi Panic Devices ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
6I hereby affirm that I am iiLensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi
ness and Professions Code and my license is in full force and PARKING
11 effect
effect REO D PROVIDED
License Number Lic Class LIMITED TIME USE
Contractor Date DATE DATE
❑ FROM TO
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO OF / INSPECTOR 5
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG STORIES �/• i SIGNATURE
iness and Professions Code) FIN L APPROV AL
PRESENT USE OF BUILDING
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS 8 1 1 8 A
ON LOT AND USE y
I hereby affirm that I am exempt from the Contractor's
tf a a a a 30
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) NO PARKING 2 0,- 8050
131,
PROVIDED I, as owner of the property, will do the work and the /o o • 5020: i
structure is not intended or offered for sale (Section I
7044,Business and Professions Code) PROPOSED USE OF BUILDING 01 10-84
CONSTRUCTION LENDING AGENCY
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 C)
Lender's Name PROPOSED MAX OCC
Lender s Address PERMIT FEE
1 certify that 1 have read this application and state that the
above information is correct I agree to comply with all County ISSUANCE FEE O
ordinances and State laws relating to building construction TOTAL FEE
and hereby authorize representatives of this County to enter
upon the above mentioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature�ermfltee Date