HomeMy Public PortalAbout5949 OAK AVE_Miscellaneous__ WORKERS COMPENSATION DECLARATION 76M444 M I SC E LLAN EO U APPLICATION
CE 875(77 84)
I hereby that I have a certificate of co nt to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure war a ter tate of Workers Compbnsation I unsurance or
a cop ithereo��c 3800 Lab C)
Po No o pally �� ► `` FOR APPLICANT TO FILL IN BUILDING /�y
v ADDRBSB $ V� T
Certified copy is hereby furnished JWILDING ADDRESS 5948 QAk A46 TeAUAIFi C YCA gC180
LocwLlrr
riCertified copy is filed with the tiiu building inspection (11-100?) NEAREST
_Tent-l2 _ CALITY CR088ST WV�JVT
Date ff.• AppliCBn NEAREST �,"/`O ..y DISTRI T Nf� ROUP TYPE PROCESSED BY
CROSS ST tV OF �� Y �� CONST I,
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL 000 (�
COMPENSATION INSURANCE DESCRIPTION LOT NO 328 ISILOCK 2_ MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO OP BLDQS ND (CIRCLs)
(This section need not be completed if the work involved TRACT Now ON LOT C)I%bG/ US6 ZONE F
ECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or Ices.) /- r_ ueE or /�
I certify that m the performance of the work for which this SIZE OP LOT �09q V�R EXISTING -Q_`
permit is issued I shall not employ any person m any manner OWNERi!% 646 ' hIL y
so as to become subject to the Workers Compensation Laws MAIL a OCCUPANCY GROUP c
Date Applicant aDDRsss ,pM/F, v
NOTICE TO APPLICANT If after making this Certificate of CITY'1 J noLSIB 2B-1 4MI_ 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 or this permit shall be TRAILER u8E❑ GEOLOGY INSPECTION❑ No Spec Knowl
deemed revoked Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑
I hereby affirm that I am licensed under provisions of Chapter
9 (commenting with Section 7000)of Division 3 of the Buso- SAFETY PERMIT ❑ (LIST ITEMS BELOW NO OF EXITS
ness and Professions Code and my license is in full force and
effect PARKING SPACES REG D PROVIDED
License Number Lic Class bQxrAle
LIMITED TIME USE
Contractor Date DATE DATZ
I am exempt from the licensing requirements as I am a FROM TO
licensed architect or a registered professional engineer SIZE oP NO 0P INSPECTOR S
acting m my professional capacity (Section 7051 Bus- EXISTING BLDG 12 $ �� sroRlss(NE
SIGNATURE
men Professions Code) 6SENT USE OF BUILDING FINAL APPROVAL O
Lic or Regeg No No Date �1�QC4 �f�t
HOME OWNER BUILDER DECLARATION No or EXISTING BUILDINGS (3f4eON LOT AND USE
o �� l[If FEE
I hereby affirm that I am exempt from the Contractor s d Ii
License Law for the following reason (Section 70315 Buri 'b0QTAr (}Oj 1i
nese and Professions Code) NO PARKING �� LMO-0001 7/20/92
I as owner of thepropertywill do the work and the SPACES PROVIDED
o 449 Z AM �7
structure is not intended or offered for sale (Section I,_
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY too PROPOSED USE OP BUILDING
I hereby affirm that there is a construction lending agency 1> ryTA-Lar+%C'e , f
for the performance of the work for winch this permit is
issued(Sec 3097 Civ C)
Lender s Name
PROPOSED MAX OCC
Lender s Address
PERMIT FEE �r�
I certify that I have read this application and state that the
above information is correct I agree to comply with all County ISSUANCE PEE
ordinances and State laws relating to building construction ti
and hereby authorize representatives of this County to enter TOTAL.PEE iO
upon t a ove boned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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S iatur9 of Permittee Date