HomeMy Public PortalAbout6012 OAK AVE_Miscellaneous__ WORKERS COMPENSATION DECLARATION 75M444
CE 875(280) MISCELLANEOUS APPLICATION {�
I hereby affirm that I have certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �J
Insure or a certificate of Workers
rs Compensation Insurance
e or
a certified copy thereof(Sec 3800 Lab C)
Policy No Company EARLE
w g
FOR APPLICANT TO FILL IN IO❑ Certified copy is hereby furnished BUILDINGDRESS �(.Id d I�' � �Certified copy is filed with the county building InspectionLOCALITY department
Date Applicant NEAREST ff DISTRICT O 1 G UP TYPE P ESSED BY
CROSS ST q� -3 CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK }
MAP (CIRCLE)
A•
No (CIRCLE) STATE MAJOR SECOND LOCAL d
(This section need not be completed If the work mvolved No of BLOcs USE ZONE SPECIAL CONDITIONS 0
P TRACT NOW ON LOT V
by the permit Is for one hundred dollars ($100) or less) usfiEXISTINofG BLDG
SIZE OF LOT v 0
' O
I certify that in the performance of the work for which this 0
permit Is issued I shall not employ any person in any manner OWNER
so as to become subject to the Workers Compensation Laws MAIL 1 OCCUPANCY GROUP ADDRESS 91.
�O/ b v -` CO)
Date Applicant � Z
NOTICE TO APPLICANT if after making this Certificate of CITY G TSL S= Q 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 NO Spec Knowla Panic Devices
❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION eIr
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO OF EXITS a
9 (commencing with Section 7000)of Division 3 of the Buss
ness and Professions Code and my license is in full force and PARKING
effect
^ D/ SPACES REG D PROVIDED
License Number Lic Class a LIMITED TIME USE
Contractor Date DATE DATE
❑
1.am exempt from the licensing requirements as I am a I
FROM TO
lcensed architect or a registered professional engineer SIZE OF NO of INSPECTOR S
acting in my professional capacity (Section 7051 Bus EXISTING BLDG l 3 STORIES S1 TURF
iness and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL
Llc or Reg No Date 1 `_�
HOME OWNER BUILDER DECLARATION No O EXISTING BUILDINGS
ON LOT AND USE d
I hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 7031 5 Buss
ness and Professions Code) SPARKING
PACfiS PROVIDED
❑ I as owner of the property will do the work and the
structure is not intended or offered for sale (Section �-
7044 Business and Professions Code) PROPOSED USE OF B ILDING
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) C I
Lender a Name r = G
PROPOSED MAX C:C .,J �1
Lender s Address PERMIT FEE - ::!j- I yF
1 certify that I have read this application and state that the �//�� Com. --I
ISSUANCE FEE
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction V r^I
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above ntioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAn :`ti
Signature of Permittee Date ` 1 ►-+ �, 0
c- 0 cl
I-+ 1_1