The URL can be used to link to this page

Home My Public Portal About5939 OAK AVE_Miscellaneous__ WORKERS COMPENSATION DECLARATION c 875(11 844 11 MIS E LAN EOUS A PPLICATI O N Lhaseby affirm that I have a certificate of consent to self COUNTY OF LOS ANG LES BUILDING AND SAFETY DIVISION msurc, or a certiticate of Workers Compensation Insurance,or _ a aertrfi%copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FI LL N BUILOINs r�� L ADDRESS a� (,. Certified copy is hereby furiushedXX wooslsss LOCALITY dCertified epartment PY is filed with the county building inspectio LOCALITY _ NEAREST CROSS ST Date Applicant NEAREST .STRICT O 7Up COs ssssD BY i cwoss sr 0. N n Op ,� t CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION WSURANCEDESCRIPTION LOT NO BLOCK MAP NloNnwY STATE MAJOR SECOND LOCAL No of SLOGS No (CMCLa) (This is Section need not be Completed if the work involved TRACT NOW ON LOT USB ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG I certify that m the performance of the work for which �� C3 permit is issued I shall not employ any person many NNER of buildin so as to become subject to the Workers Compensation La AIL OCCUPANCY GROUP a Date Applicant ADDRESS ✓e S 1� NOTICE TO APPLICANT If after making this Certificate of CITY e — TRI. _ 6l 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[3 GEOLOGY INSPECTION❑ No Spec Knowl deemed revoked. LICENSED CONTRACTORS DECLARATION t OCCUPANCY INSPECTION[3 Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT[3 (LIST ITEMS BELOW) 9 (commencing with Section 7000)of Division 3 of the Bu No or sXlrs ness and Professions Code and my he sine is in fail force effect AIIle of business PARKING SPACES REQ D 1 J PROVIDED License Number LIC Class Z:bu 162 ISE21 LIMITED TIME USE Contractor Date DATE DATE To I am exempt from the licensing requirements as I am a Pear= licensed architect or a registered professional engineer SIRE of No of Nt"I R s acting in my professional capacity (Section 70S1 Bus- EXISTING BLDG STORIES s mess and Professions Code) ' FINAL APPROVAL Lic or Reg No Date I PRESENT YBB OR BUILDING VIN:I1,11L/� IcC HOME OWNER BUILDER DECLARATION S No of EXISTING BUILDINGS (� fl� ,A U137 1� ON LOT AND USE v U I hereby affirm that 1 am exempt from the Contractors ' License Law for the following reason (Section 70315 Buw ' ) I, ness and Professions Code) No PARKING I as owner of the property, will do the work and the d SPACES PROVIDED structure is not intended or offered for sale (Section 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a constriction lending agency ! for the performance of the work for which this permit is Issued(Sec 3097 Civ C) Lender a Name r PROPOSED MAX OCC Lender a Address 1 certify that I have read this application and state that the PERMIT Fes 25.00 above information is correct 1 agree to comply with all County ISSUANCE Fes ordinances and State laws relating to building construction and hereby authorize representatives of this County to enter TOTAL.PEE 25.00 the above-mentioned property for ti it purposes { SEE REVERSE FOR EXPLANATORY LANGUAGE S SignalumpfPermittlif Date � a WORkI:RS COMPENSATION DECLARAI1014 ,K, MISCELLANEOUS APPLICATION 1 I �o t I hereby affirm that i have a cc tlftcate of Lonsent to , oot,aDPw 1.11 COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Il insure or a certificate of Workers Compensation IncurancL or a certified copy thereof(Sec 3800 Lab C) Polic% No _ Compam _ _ FOR APPLICANT TO FILL IN BUILDIN- X BU LDING AODRE S ADDRESS Ulm Certified cop) is hereto furnished 3C'/ iqK LOCAU v Certified cop) Is filed with the count) buridrnE.Inspection CITY ZIP NEARE T department I CROSS ST Ddte _ Applicant_ ___ SIZE OF LOT NO OF DGS NOW ON LOT DISTR S N- GRQI�p TYPE ESSED BY r CERTIFICATE OF EXEMPTION FROM %%ORLERS !1/J000y /tjJt CONST COMPENSATION INSURANCE TRACT (BLOCK LOT NO MAP NGNWAY t No CIRCLE STATE MA OR SECOND LOCAL (This section need not be completed If thL Aork In%ol%ed ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS b) the permit Is for one hundred dollar+ IS100) or less) 1 LernI% fit it In the performance of thL worl Ior which Ihl OWNER TEL NO permit is usuLd I bh ill not emplo% am pu+on In Int manixf property � f' ?Qt's 0 so aL to become Tubi-ct to the 1loorlers Compenbduon Law ADORE r t O�CUPANCf GROUP � mai 3S� S a.nl1 m _ Date _ 4ppflcan[ Y I ZIP p!/D/ NOTICE TO APPLICANT if Teter mal.ro, this Cerullcat& a OCCUPANT LOAD of Exemption Lou should becom- buotect to the 11ori.erb ADPLICATION FOR EO IT HARDWARE Compensation p o%iti on of the Labo Code Lou must torthwlth comph with su^i pren Istonb or thl permit shall bL debited TRAILER USE v GEOLOGY INSPECTION IJ No Spec hnovi ❑ re.ol.-d LICENSED C U\TR ACTO(.S DEC L Ah ATI(O\ OCCUPANCI INS=ECT10N J Panic Devices 1 hereh% aft Irm that 1 am licenses under prat(Shin+of C h Ipwr SAFETY PERMIT U LIST ITEMS B w 9 teomm-nein-w ith S-coon 70001 of Dn i+inn of the Bubines NO OF EXITS and Proteb+Ions Cod and ml licen+- I it Iull for c Ind CIILct r� PARKING REO D U I PRO\TOED i�l LIc-rise \i Tiber LI (I 1+ SPACES , cont Ict< _ _ Dit- LIMITED TIME USE ' DATE DATE 131 im e%empt 1r im the hcen+ut_ rcyulrun..nt 1 I im i FROM TO 11 Lnb d IrchuL^r i t I r-_i%iLrLd pIOIL++IIIn If ut_InLLr actin_ In mL Aral-+,(anal Lap Tun I tiLLlJoll 70,l Bu utL„ 'ZENO OF INSPECTOR b and Prott„Tun (lyde) I XIS TNG BLDG I STORIES SIGNATURE Lic or ReF No D IIL F RESENT USE OF BUILDING FINAL ADPRO00 HOME 011 NER BLIILDLIL DEC I %I%%I ION 110 OF EXISTING BUI_DI-JZ- � , /f�' C - dn7IF_E ''/19/ U ON LOT AND USE I hereb% affirm that I im ciempi from thL (ontrictor,Lrcen%e 0411 1 FI I ;0 Lax for the followute reison ISLctlun 7011-1 BUSIIttbS and Profession+ Code) NO PARKING ❑ I as owner Of the -PACES PROVIDED pmpertt toil da ilii wail uta th� structure is not intended or offered for safe(Section 7(t.1-I PROPOSED USE OF BUILDING Business and Professions Code) CONSTRUCTION LENDING AGENC 1 I hereb% affirm that there is a construction lending dgenc% fur the performance of the wort for which thi% permit i% i%sued PROPOSED MAX oee ' (Sec 3097 Cit C) Lender s Name APPLICANT IFRINI i TEL NO Lender s Address ___ ADDRESS I ctnif) that I have read this application and state that the above information is correct 1 agree to comply with all Count) P.RM1T FEE ordinances and State laws relating to building construction and herrb) authorize representatives of this Count% to enter upon ISSUANCE FEE the above mentioned propern for Inspection puryx)%e+ TOTAL FEE X 7"l� �aw SEE RE%ERSC FOI, EXPLANATORI LANGI AGE L