HomeMy Public PortalAbout5755 OAK AVE_Miscellaneous__ YVORKER$ COMPENSATION DECLARATION �E 8i54(tt 84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to c 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)
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS 55 WP'-L
Certified copy is hereby furnished BUILDING
AD DR BSS LOCALITY
Certified copy is filed with the county building inspection7 NEwItEST
department LOCALITtqp4a 1 170 CROSS ST
Date Applicant NEAREST 0 Ad ADISTRICT NQQQ,, GROUP TYPE PR ESSED BY
CROSS ST M (/ 2 CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL va J �/
COMPENSATION INSURANCE DESCRIPTION LOT NO114 BLOCK NAP HIGHWAY STATE MAJOR SECOND LOCAL
NO OF BLDGS No (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) non of /
I certify that in the performance of the work for which this SIZE OF LOT 6Q EXISTING BLDG S•
permit is issued I shall not employ any person many manner OWNER 4JOS ENA AW. QU#e v
so as to become subject to the Workers Compensation Laws MAIL �+/�.� OCCUPANCY GROUP o a
Date Applicant ADDRESS J /SS r`
NOTICE TO APPLICANT If after making this Certificate of CITY A"P ITvoL a�I _ OCCUPANT LOAD
Jr
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 E] GEOLOGY INSPECTION❑ No Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW)
9 (commenting with Section 7000)of Division 3 of the Busy NO of EXITS
ness and Professions Code and my license is in full force and -.^�
effect V ��C_l.O �lE� -1-=q4L. PARKING REQ D PROVIDED
SPACES 11��
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 INSPECTOR 8
licensed architect or a registered professional engineer Sas OF NO OF
acting m my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL
Lic or Reg No Date PRESENT USB OR BUILDING L,51 ID L.. ,��
HOME OWNER BUILDER DECLARATIONNO OF EXISTING BUILDINGS `L _
ON LOT AND USE S(�I� CE tilt i
I hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 70315 Busi- 'GAP�1N. � 3=17 9Z.01
ness and Professions Code) NO PARKING r
I as owner of the property will do the work and the SPACES PROVIDED y 1l:.
T G
structure is not intended or offered for sale (Section VITAL93.00
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY
PROPOSED USE OF BUILDING �iJ�6E gNli� ADA 93.66
I hereby affirm that there is a construction lending agency CHANGE •011
for the performance of the work for winch this permit is
issued(Sec 3097 Civ C)
Lender s Name 00CC—COC 1 7J :/91
PROPOSED MAX OCC
Lender s Address
I certify that I have read this application and state that the PERMIT FEE o 7328 1 AM 7°+i
above information is correct I 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 REE04
upon the above mentioned property for inspection purposes
1,
7 SEE REVERSE FOR EXPLANATORY LANGUAGE
`)_Filure of Permit ee Da