HomeMy Public PortalAbout6437 OAK AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATI®N
t 20-0083DPW 12/90
I hereby affirm that 1 have a certificate of consont to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �I
insure,or a certifigpte of Workers'Compensation Insurance, or •- u
a certifieZr copy thereof(Sec. 3800. Lab.C.) 0
Policy No.-__ _ Company 4_ _ FOR APPLICANT TO FILL IN BUILDING
BUILDING ADDRESS ADDRESS G/ //
❑ Certified copy is hereby furnished. 6437 N. 04K AVEE LOCALITY !
❑ Certified copy is filed with the county building inspection CITY ZIP NEAREST
department. 7EM LE C41Y C q 91Z80 CROSS ST.
Date_ – Applicant __ - - SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE P ESSED BY
CERTIFICATE OF EXEMPTION FROM WORKERS' 00 ! ��+� 3 CONST. O
COMPENSATION INSURANCE TRACT BLOCK LOT NO. MAP HIGHWAY V
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
(This Section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL NO.USE
SPECIAL CONDITIONS
by the permit is for one hundred dollars (S 100) or less.) Q
I certify that in the performance of the work for which this 'OWNER TEL NO. bpermit is issued, I shall not employ any person in any manner CrCCILI A I4UYAIH a/9 6.20_ a( UJ
so as to become subject to the Workers Compensation Laws.
ADDRESS ��E OCCUPANCY GROUP Lem )
Date _ _ Applicant _ _ _ CITY" �f zIP �0 LLee��JJ
NOTICE TO APPLICANT: If, after making this Certificate +"! C4 f OCCUPANT LOAD
of Exemption, you should become subject to the Workers' APPLICATION FOR
Compensation provisions of the Labor Code,you must forthwith EXIT HARDWARE:
comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑
revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
El
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW 1
9(commencing with Section 7000)of Division 3 of the Business No.OF EXITS
and Professions Code,and my license is in full force and effect. a '�J 6.ti PARKING
License Number - --- -- Lic. Class SPACES REq'D D PROVIDED
Contractor ___—__-_ _--__ Date X % LIMITED TIME USE
�.
El DATE I am exempt from the licensing requirements as I am a OM: TO: DATE
licensed architect or a registered professional engineer '
acting in my professional capacity(Section 7051• Business SIZEOF NO.OF INSP OR's
and Professions Code). EXISTING BLDG. STORIES S RE
Lic.or Reg. No._– _ _– _— – Date – -_ PRESENT USE OF BUILDING /J FINAL APPROVAL 2Z M
HOME OWNER-BUILDER DECLARATION NO.OF FXISTING BUILDINGS 3 � 74�o�Q
ON LOT AND USE i
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5• Business and 1 ITEMS
Professions Code): NO.PARKINGTOTAL - '�►
SPACES PROVIDED p
❑ 1, as owner of the property, will do the work pnd the
structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING CHECK 242.70
Business and Professions Code). 91411 �n JYN ;"
CHANGE .00
CONSTRUCTION LENDING AGENCY (�,,•y� j �
I hereby affirm that there is a construction lending agency for /VT""
the performance of the work for which this permit is issued 000070001 12121/95
(Sea 3097, Civ. C.). PROPOSED MAX.OCG p{�O p
Lender's Name ____ ___ --____— ____ _– _ APPLICANT(PRINT) TEL No. 3909 1 AN 8:5p
LIA
Lender's Address —_ _-_ - _-- ADDRESS U N ala) GZO_ d1
1 certify that I have read this application and state that the �411 Q4k MJE-MELE cA q17go
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,and PERMIT FEE
hereby authorize representatives of this County to enter upon ISSUANCE FEE 30
the above-mentioned property for inspection purposes.
TOTAL FEE c�R 17 '7 .
z U. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of PifpiittcTe Date